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THE  PRACTICE  OF 


PEDIATRICS 


BY 

CHARLES  GILMORE  KERLEY 

Professor  of  Diseases  of  Children  in  the  New  York  Polyclinic  Medical  School  and 
Hospital;    Attending   Physician  to  the  New  York   Nursery  and   Child's  Hos- 
pital; Consulting  Physician  to  the  Babies'  Hospital;  Consulting    Physician 
to  the  Sevilla  Home  for  Girls  and  to   the  New  York  Home  for  Des- 
titute and  Crippled  Children;  Consulting  Pediatrist  to  the  Green- 
wich  (Conn.)   Hospital,   to   the  Tarrytown    (N.  Y.)  Hospital, 
to  the  Englewood  (N.  J.)  Hospital,  and  to  the  Lawrence 
(Bronxville)  Hospital;  Ex-President  American  Pediatric 
Society;  Ex-President  New  York  County  Medical 
Society 


SECOND  EDITION.  REVISED  AND  RESET 


PHILADELPHIA  AND  LONDON 

W.  B.  SAUNDERS  COMPANY 

1918 


Copyright,  1914,  by  W.  B.  Saunders  Company.    Reprinted  July,  1914,  February,  1915,  and 
October,  1915.     Revised,  entirely  reset,  reprinted,  and  recopyrighted  January,  1918 


Copyright,  1918,  by  W.  B.  Saunders  Company 


PRINTED    IN    AMERICA 

PRESS    OF 

W.    B.    SAUNDERS    COMPANY 

PHILADELPHIA 


K 


TO 
MY   PRACTITIONER   STUDENTS 

PAST  AND  PRESENT 


iSfEW  YORK  POLYCLINIC  MEDICAL  SCHOOL  AND  HOSPITAL, 

AT  WHOSE  SUGGESTION 

THIS  WORK  HAS  BEEN  PREPARED 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/practiceofpediat1920kerl 


PREFACE  TO  THE  SECOND  EDITION 


The  progress  made  in  Pediatrics  since  the  previous  edition  in  1914 
has  necessitated  many  changes  in  this  volume.  Twenty-five  new 
articles  have  been  added,  sixteen  chapters  largely  re-written  and 
lesser  changes  made  in  many  others.  A  great  deal  of  old  material 
has  been  removed  and  in  its  place  has  been  substituted  that  which  it 
is  hoped  will  be  of  more  service  to  the  practitioner  and  student. 

C.  G.  K. 

New  York  City, 
January,  1918. 


11 


CONTENTS 


Page 

The  Newly  Born 17 

Nutrition  and  Growth,  17— Maternal  Nursing,  21 — Human  Milk,  31 — - 
Wet-nurse,  33 — The  Breast,  34 — The  Nursery,  36 — The  Nursery-maid,  38 
— Weight,  38 — Height,  41— The  Care  of  the  Stump  of  the  Umbilical  Cord, 
41 — Mental  and  Physical  Development  in  the  Infant,  42 — Baskets  for 
Early  Exercises,  44 — Crying,  44 — Sleep,  45 — Stools,  46 — The  Nursing- 
bottle  and  Nipple,  47 — Substitute  Breast-feeding;  Artificial  Feeding, 
48— Cow's  Milk,  49— Modified  Milk,  54— Cereal  Gruels;  Starch-feed- 
ing, 66 — Peptonized  Milk,  68 — ^Milk  for  Traveling,  69 — Food  Formulas, 
70 — The  Proprietary  Foods,  71 — Cream,  73 — Sterilization  and  Pasteuri- 
zation of  Milk,  74 — The  Effect  of  Heating  Milk  upon  its  Assimilation,  77 
— Scientific  Infant-feeding,  78 — Habitual  Loss  of  Appetite,  79 — Sub- 
stitutes for  Stomach-feeding,  81 — Disorders  of  Nutrition,  86 — Marasmus 
(Arthrepsia;  Infantile  Atrophy),  86 — Malnutrition  in  Infants,  92 — The 
Ammoniacal  Diaper,  100 — Tardy  Malnutrition  and  Malnutrition  in 
Older  Children,  100— Feeding  after  the  First  Year,  102 — General  Proper- 
ties of  Foods,  102  — Diet  from  the  First  to  the  Sixth  Year,  105 — Diet 
after  the  Sixth  Year,  108 — Diet  during  Illness,  109 — Common  Errors 
in  Feeding,  110 — Scurvy  (Scorbutus),  111 — Rachitis  (Rickets),  115 — The 
Delicate  Child,  122. 

Examination  and  Diagnosis — Care  of  Acute  Illness 130 

Diagnosis,  130 — First  Examination,  132— Essentials  in  the  Care  of 
Acute  Illness,  133 — The  Sick-room,  137 — Necessity  of  Method  in  the 
Management  of  Children,  138 — Treatment  of  the  Individual,  139. 

Diseases  of  the  New-born 140 

Premature  and  Congenitally  Weak  Infants,  140 — Cephalhematoma,  142 
— Icterus,  143 — Sclerema,  145 — Sepsis,  146 — Asphyxia,  148 — Delayed 
Asphyxia,  152 — -Atelectasis,  152 — Amyotonia  Congenita  (Oppenheim's 
Disease),  153 — Congenital  Absence  of  Bile-ducts,  153 — Umbilical  Gran- 
uloma, 154— Umbilical  Polyp,  154 — Mastitis,  155 — Tetanus,  156 — Hem- 
orrhagic Diseases,  157. 

Diseases  of  the  Mouth  and  Esophagus 162 

Sprue  (Thrush;  Mycotic  Stomatitis),  162 — Stomatitis,  163 — Cancrum 
Oris  (Noma),  166 — Fissure  of  Lips,  167 — Geographic  Tongue,  167 — 
Ulcerations  and  Fissures  at  the  Angle  of  the  Mouth,  168 — Harelip  and 
Cleft-palate,  168— The  Teeth,  169— Malformation  of  the  Esophagus,  171. 

Diseases  of  the  Stomach,  Intestines,  and  Peritoneum 172 

The  Stomach,  172 — Acute  Gastritis  and  Acute  Gastric  Indigestion,  173 — 
Chronic  Gastric  Indigestion  (Chronic  Gastritis),  175 — Chronic  Dilatation 
of  the  Stomach,  176 — Ptoses  and  Dilatation  of  Stomach  in  Older  Children, 
177 — Hemorrhage  from  the  Stomach;  Vomiting  Blood,  182 — Ulceration 
of  Stomach,  183 — Duodenal  Ulcer,  184 — The  Management  of  Vomiting 
Babies,  185 — Pyloric  Stenosis,  185 — Acute  Gastro-enteric  Intoxication, 
193 — Gastro-enteric  Intoxication,  194 — Acute  Enteric  Intoxication,  201 
— Acute  Intestinal  Indigestion,  204 — Persistent  Intestinal  Indigestion, 
205 — Persistent  Intestinal  Indigestion  in  Older  Children,  206 — j\Icchan- 
ical  Agencies  as  Cause  of  Digestive  Disturbances,  208 — Colic,  214 — Pre- 
A'-ention  of  the  Acute  Intestinal  Diseases  of  Summer,  216 — Vomiting, 
219— Rumination,  220— Acute  Ileocolitis  (Dysentery),  220 — Chronic 
Ileocolitis,  227 — Mucous  Colitis,  229 — Hirschsprung's  Disease  (Idio- 
pathic Dilatation  of  the  Colon),  230— Intestinal  Infantilism  of  Herter, 
231 — Incontinence  of  Feces,  232 — Intussusception,  233 — Constipation, 
236 — Intestinal  Obstruction,  244 — Intestinal  Cysts  or  Diverticula  (Con- 
genital), 246 — The  Intestinal  Parasites,  247 — Appendicitis,  252 — Chronic 
Appendicitis,  255 — Acute  General  Peritonitis,  256 — Peritonitis  as  a 
Complication,  256. 

13 


14  CONTENTS 

Page 

The  Rectum  and  Anus 258 

The  Rectum  in  Children,  258 — Prolapse  of  the  Anus  and  Rectum,  258^ 
Inflammation  of  the  Anus,  260 — Fissure  of  the  Anus,  260 — Proctitis,  261 — 
Ischiorectal  Abscess,  262. 

The  Spleen  and  the  Liver 263 

The  Spleen,  263— Splenomegaly,  263— The  Liver,  263— Icterus  (Obstruc- 
tive Jaundice;  Catarrhal  Jaundice),  265. 

Diseases  of  the  Respiratory  Tract 267 

The  Nose  and  Throat,  267 — Acute  Rhinitis  (Coryza;  Snuffles;  Cold  in  the 
Head),  267 — Chronic  Rhinitis  (Nasal  Catarrh),,  269— Nasal  Hemorrhage, 
271 — Throat  Examination,  271 — Persistent  Cough,  272 — Faucitis,  273 — 
Pharyngitis,  274 — Retropharyngeal  Adenitis,  275— Acute  Retrophaiyn- 
geal  Abscess,  275 — Retropharyngeal  Abscess — Tuberculous  Caries  of  the 
Cervical  Vertebraj,  278— Irrigation  of  the  Throat,  278— The  Tonsils,  279 
— Tonsillitis — Acute  Follicular  Tonsillitis,  280 — Peritonsillar  Abscess 
(Quinsy),  283 — Vincent's  Angina,  285 — Septic  Sore  Throat  (Milk  Borne), 
286 — Acute  Catarrhal  Laryngitis  (Spasmodic  Croup),  287 — Traumatic 
Laryngitis,  291 — ^Laryngeal  Obstruction,  292 — Foreign  Bodies  in  the 
Larvnx,  292 — Adenoids,  293 — Hypertrophied  and  Permanently  Diseased 
Tonsils,  297— Pollinosis,  Pollen  Disease,  Hay  Fever,  301 — The  Lungs,  302 
— Examination  of  Lungs,  302 — ^Bronchitis,  310 — Recurrent  Bronchitis, 
314 — Acute  Spasmodic  Bronchitis  (Bronchial  Asthma),  316 — Pneu- 
monia, 320 — Lobar  Pneumonia,  320 — Bronchopneumonia  (Catarrhal 
Pneumonia),  332 — Interstitial  Pneumonia,  Including  Bronchiectasis,  342 
— Hypostatic  Pneumonia,  345 — Pneumothorax,  345— Emphysema,  346 — 
Subcutaneous  Emphysema  (Emphysema  of  Mediastinum),  347 — Primary 
Pleurisy,  348 — Secondary  Pleurisy,  348 — Empyema  (Pleurisy  with  Puru- 
lent Effusion),  351 — Pulmonary  Gangrene,  360 — Pulmonary  Abscess, 
360 — Pulmonary  Tuberculosis,  361 — Heliotherapy,  366. 

Diseases  of  the  Heart 368 

Diagnosis  in  Diseases  of  the  Heart,  368 — Heart  Murmurs,  370 — Peri- 
carditis, 374 — Acute  Endocarditis,  377 — Myocarditis,  383 — Congenital 
Heart  Disease,  386 — Acute  Endocarditis,  378 — Chronic  Valvular  Disease 
of  the  Heart,  389 — Adherent  Pericardium,  393. 

The  Blood  and  Blood  Diseases 394 

Blood  in  the  Newly  Born,  394 — Blood  in  Infancy  or  Childhood,  394 — ^The 
Blood  in  Different  Diseases,  397 — Blood-pressure  in  Children,  401 — 
Coagulation  Time,  402 — Anemia,  402 — Chlorosis,  405 — Pseudoleukemic 
Anemia  of  von  Jaksch,  406 — ^Leukemia,  407 — Pernicious  Anemia,  408 — 
Purpura,  409,  Hemophilia  (Bleeder's  Disease),  411 — Hodgkin's  Disease 
(Lymphadenoma),  413. 

The  Glandular  System 415 

Diseases  of  the  Lymphatic  Glands,  415 — Acute  Cervical  Adenitis,  415 — 
Persistent  Simple  Adenitis,  418 — Glandular  Fever,  419 — Tuberculous 
Adenitis,  420— Mastitis  in  Young  Girls,  422— The  Thymus  Gland,  423— 
Status  Lymphaticus,  424 — Dyspituitarism.  Dystrophy  Adiposogenitalis 
(Frohlich),  428. 

The    Urogenital  System 429 

The  Urine,  429 — Difficult  and  Painful  Urination,  430 — Retention  and 
Suppression  of  Urine,  430 — Incontinence  of  Urine  (Enuresis),  432; — 
Hematuria  (Blood  in  the  Urine),  436— Hemoglobinuria,  436 — Pyuria, 
436 — Glycosuria,  437 — The  Kidneys,  438 — Tuberculosis  of  the  Kidney, 
438 — New  Growths  of  the  Kidney,  438 — Hydronephrosis  and  Pyonephro- 
sis, 439 — Cysts  of  the  Kidney,  441 — Acute  Parenchymatous  Nephritis 
(Acute  Diffuse  Nephritis),  441 — Chronic  Diffuse  Nephritis,  449— Chronic 
Interstitial  Nephritis,  452 — Orthostatic  All^uminuria,  452 — Pyelocystitis 
CPyolitis),  453 — Precocious  Menstruation  and  Precocious  Maturity,  456 — 
the  Bladder,  457 — Cystitis,  457— Vesical  Calculus  (Stone  in  the  Bladder), 
458— Exstrophy  of  the  Bladder,  458— The  Male  Genitals,  459— Balanitis, 
459 — Phimosis,"  460 — Paraphimosis,  461 — Circumcision,  461 — Unde- 
scended Testicle,  462 — Orchitis,  462 — Hydrocele,  463 — Gonorrhea  in  the 
Male,  464 — Epispadias  anrl  Hypospadias,  464 — The  Female  Genitals,  465 
— Vidvovaginitis  (Simple),  465 — Gonorrheal  Vulvovaginitis  (Specific 
Vaginitis),  466 — Atresia  of  the  Urethra  and  Vagina,  469. 


CONTENTS  15 

Page 

Nervous    Disorders.    .    .    ; 470 

Headache,  470 — Pavor  Diurnus,  470 — Night-terrors  (Pavor  Nocturnus), 
471 — Gyrospasm  (Spasmus  Nutans),  472 — Hysteria,  472 — Habits,  477 — 
Masturbation,  479 — Hiccup,  483 — Infantile  Convulsions,  483 — Laryngis- 
mus Stridulus,  487 — Spasmophilia,  489 — Congenital  Stridor,  491 — Tetany, 
491 — Insanity,  497 — Malformations  of  the  Brain  and  Cord,  499 — Type 
and  Incidence  of  Brain  Tumor,  502 — Mentally  Deficient  Children  (Imbe- 
cility; Idiocy),  503 — Mongolian  Idiocy,  503 — Amaurotic  Family  Idiocy, 
507 — Hydrocephalus,  509 — Cerebral  Palsies — The  Prenatal  and  Birth 
Forms,  513 — The  Acquired  Form,  515 — Chorea  (St.  Vitus'  Dance),  518 — 
Habit  Spasm  (Tic),  524 — Stammering,  525 — The  Progressive  Muscular 
Atrophies,  526 — Progressive  Spinal  Muscular  Atrophy  or  Progressive 
Amyotrophy,  526 — The  Progressive  Amyotrophies  (Primary  Muscular 
Dystrophies),  530 — Epilepsy,  531 — Acute  Poliomvelitis  (Infantile  Paraly- 
sis), 535— Multiple  Neuritis,  542— Facial_  Palsy,  546— Erb's  Palsy 
(Obstetric  Paralysis),  547 — Friedreich's  Ataxia  (Hereditary  Ataxia),  548 — 
Acute  Infective  Meningitis,  550 — Tuberculous  Meningitis,  553 — Cerebro- 
spinal Meningitis,  557 — Meningismus  (Serous  Meningitis),  565 — Lumbar 
Puncture,  566. 

Diseases  of  the  Skin 568 

Miliaria  (Prickly  Heat),  569 — Urticaria  (Hives;  Nettle-rash),  570 — Rhus 
Poisoning  (Ivy  Poisoning),  571 — Scabies  (Itch),  572- — Furunculosis 
(Boils),  573 — Pediculi  (Head  Lice),  514 — Tinea  Circinata  (Ring-worm), 
575 — -Tinea  Tonsurans  (Ring-worm  of  the  Scalp),  576 — Impetigo  Contag- 
iosa, 579 — Pemphigus  Neonatorum,  579 — Erythema  Nodosum,  580 — 
Erythema  Multiforme,  581 — Erysipelas,  581 — Eczema,  584 — Eczema  ■ 
Intertrigo  or  Erythema  Intertrigo,  590 — Eczema  in  Older  Children,  591 — 
Seborrhea,  595 — Psoriasis,  597— Bed-sores  (Decubitus),  597 — Nevus 
Birthmark),  598. 

Diseases  of  the  Ear 600 

Earache,  600 — Deafness,  600 — Acute  Otitis,  601 — Chronic  Suppui-ative 
Otitis,  605— Mastoiditis,  606— Sinus  Thrombosis,  606. 

The    Transmissible    Diseases 608 

Care  to  be  Exercised  by  Physician  in  Visiting  Infectious  and  Contagious 
Diseases,  609 — -Varicella  (Chicken-pox),  609 — Mumps  (Epidemic  or  Spe- 
cific Parotitis),  611 — Whooping-cough  (Pertussis),  614 — Measles,  619 — 
German  Measles  (Rotheln;  Rubella),  624 — Diphtheria,  625 — Scarlet 
Fever  (Scarlatina),  643 — Typhoid  Fever,  657 — Malaria,  666 — Influenza, 
670 — Syphilis,  677 — Acute  Hereditary  or  Congenital  Syphilis,  678 — Ac- 
quired Syphilis,  685 — Tardy  Hereditary  Syphilis,  685 — Tuberculosis, 
691 — ^ Abdominal  Tuberculosis  (Tuberculosis  of  the  Mesenteric  Gland; 
Tabes  Mesenterica),  694 — Chronic  Tuberculous  Peritonitis,  695 — Dac- 
tylitis, 699— The  Newer  Diagnostic  Methods,  701— Tuberculosis,  701 — 
Tuberculin  Skin  Reactions,  703 — Wassermann  Test  for  Syphilis,  70-4 — 
Noguchi  Butyric-acid  Test  for  Syphilis,  705— Luetin  Test,  706— The 
Widal  Reaction  for  Typhoid  Fever,  707 — Anaphylaxis,  708. 

Unclassified    Diseases 709 

Rheumatism,  709 — Acidosis,  713 — Cyclic  Vomiting  (Recurrent  or  Peri- 
odic Vomiting),  715 — Cyclic  Diarrhea,  719 — Periodic  Fever,  720 — Rheu- 
matic Fever  (Acute  Rheumatism),  721 — Rheumatoid  Arthritis;  Arthritis 
Deformans;  Still's  Disease,  724 — Chondrodystrophia  (Achondroplasia), 
725 — Cretinism  (Infantile  Myxedema;  Cretinoid  Idiocy),  727 — Dwarfs, 
733 — ^Diabetes  Insipidus,  734 — Diabetes  Mellitus,  735 — Acetonuria  in 
Children,  737— Pellagra,  738— Beriberi,  740. 

Miscellaneous     Subjects 743 

Heredity  and  Environment,  743 — Consanguinity,  744 — Temperature  in 
Children,  744 — Obscure  Elevations  of  Temperature,  747 — Anesthetics, 
750 — Carcinoma,  751 — Obesity,  752 — Hematoma  of  the  Sternocleidomas- 
toid, 752 — Hernia  at  the  Umbilicus,  753 — Hernia  of  the  Umbilical  Cord, 
753 — Congenital  Umbilical  Plernia,  754 — Inguinal  Hernia,  755 — Ventral 
Hernia,  756 — Diagnosis  in  Bone  and  Joint  Diseases,  757. 

Suggestions  in  Management 760 

Vaccination,  760— Days  to  go  Out-of- Doors ;  Indoor  Airing,  762 — Instruc- 
tions for  the  Summer,  763 — The  Exercise  Pen,  767 — Summer  Resorts, 
768- Foreign  Bodies  Swallowed,  768. 


16  CONTENTS 

Page 

Therapeutic  Measures \    , 771 

Therapeutics  in  Children,  771 — The  Therapeutic  Value  of  Climate,  773 — 
Counterirritants,  775 — Cold  Sponging  in  Fever,  776 — The  Cool  Pack, 
777 — :Baths,  778 — Bathing  the  Sick,  781 — Unpalatable  and  Nauseating 
Drugs,  781-^ Alcohol,  783 — Heat  as  a  Therapeutic  Agent,  78^ — Cold  as  a 
Therapeutic  Agent,  785 — Blood  Transfusion  and  Intramuscular  Injection, 
786 — ^Lavage — Stomach-washing,  788 — Gavage,  790 — Colon  Irrigation, 
793 — Colon  -  Flushing,  795 — Hypodermoclysis,  796 — Vaccine  Therapy, 
797. 

Gymnastic  Therapeutics 803 

Rules,  803— Posture  and  Breathing,  806— Breathing,  812— Flat  Chest,  815 
— Kyphosis,  817 — Scoliosis,  820 — Empyema,  825 — Emphysema,  827— 
Congenital  Ataxias,  829 — Anterior  Poliomyelitis,  841 — ^Constipation, 
843— Flat-foot,  844. 

Drugs  and  Drug  Dosage 847 

Drugs  for  Internal  Use,  847 — Drugs  for  External  Use,  859. 

Index 865 


THE  PRACTICE  OF  PEDIATRICS 


I.  THE  NEWLY  BORN— NUTRITION— GROWTH 
Nutrition  and  Growth 

The  fundamental  principles  in  the  life  of  the  young  of  all  animals 
are  growth  and  development.  This  statement  applies  to  the  young 
of  the  lower  animals  as  well  as  to  man.  Nature  has  fixed  and  definite 
laws  in  accordance  with  which  this  growth  and  development  proceed. 
The  type  of  animal  produced  depends  in  no  small  degree  upon  the  way 
in  which-  we  comply  with  nature's  laws. 

Heredity. — Heredity  is,  of  course,  an  important  factor,  but  environ- 
ment counts  for  more.  The  young  of  the  lower  animals  or  of  man  may 
possess  all  that  can  be  desired  in  the  way  of  heredity,  but  if  manage- 
ment during  growth  is  faulty,  the  adult  is  almost  certain  to  fall  short 
of  the  normal.  On  the  other  hand,  an  individual  without  the  benefits 
of  good  heredity,  when  given  the  advantages  of  faithful  scientific  care 
may  develop  into  an  adult  decidedly  superior  in  all  respects  to  those 
more  fortunate  in  birth.  I  have  seen  this  demonstrated  repeatedly, 
both  in  the  lower  animals  and  in  man. 

Environment. — From  my  earliest  recollection  I  have  carefully 
watched  the  growth  and  development  of  animals.  By  observing  care 
as  to  feeding,  housing,  ventilation,  cleanliness,  and  exercise,  I  have  seen 
animals  which  promised  but  little  at  birth  develop  into  perfect  mature 
specimens  of  their  kind.  During  the  past  twenty-eight  years  I  have 
been  intimately  associated  with  thousands  of  infants  and  growing 
children  in  private,  in  hospital,  and  in  out-patient  work.  The  possi- 
bilities of  proper  growth  under  good  management  when  little  was  to  be 
expected,  judging  from  the  original  condition  of  the  patient,  have  been 
impressed  upon  me  repeatedly. 

The  child  is  here  through  no  choice  of  his  own.  He  is  to  have  a 
future.  His  health,  vigor,  powers  of  resistance,  happiness,  and  useful- 
ness as  a  citizen  are  determined  in  no  small  degree  by  the  nature  of  his 
care  during  the  first  fifteen  years  of  life.  He  has  a  right  to  demand  that 
such  care  be  given  him  as  will  be  conducive  at  least  to  a  sound,  well- 
developed  body,  and  this  should  be  our  first  thought  and  object  regard- 
ing him.  Consider  for  a  moment  the  number  of  occupations,  other 
than  those  of  the  army  and  the  navy,  which  require  physical  fitness 
before  a  candidate  is  accepted.  Competition  is  keen  at  the  present 
time  and  will  be  keener  in  the  future.  Employers  of  men  and 
women,  whether  in  the  office,  the  factory,  or  on  the  farm,  cannot 
afford  to  employ  the  physically  weak. 
2  17 


18  THE    PRACTICE    OF    PEDIATRICS 

The  most  important  factor  in  the  making  of  men  and  women  is 
nutrition.  No  great  power  of  reasoning  is  required  to  appreciate  the 
fact  that  the  child  who  is  fed  on  suitable  food  will  become  a  more  vigor- 
ous, better  developed  adult  than  one  who,  beginning  with  his  birth  and 
continuing  throughout  the  entire  period  of  his  growth,  is  given  only- 
food  possessing  indifferent  qualities  for  tissue  building.  Next  in  im- 
portance to  food,  and  following  in  close  succession,  are  fresh  air,  clean- 
liness, cheerful  surroundings,  and  healthful  amusements,  together  with 
an  absence  of  school  work  or  service  of  an  arduous  nature.  That  the 
offspring  of  man  suffers  more  from  nutritional  errors  due  to  the  lack 
of  suitable  care  than  do  the  young  of  the  lower  animals  is  lamentable, 
but  nevertheless  a  fact.  The  absence  of  thought  and  care  and  of 
knowledge  relating  to  children  is  due  to  the  fact  that  the  child  as  such 
has  apparently  no  intrinsic  value  in  dollars  and  cents,  whereas  the 
young  of  the  lower  animals  represent  no  small  part  of  their  owner's 
material  possessions. 

Feeding. — Success  in  the  entire  management  of  children  demands 
daily  attention  to  detail.  Feeding  the  child  properly  one  or  two 
months  out  of  the  year  is  of  little  value.  He  should  be  fed  properly 
every  day  in  the  year,  for  under  normal  conditions  every  day  is  a  day  of 
growth.  Another  factor  having  a  deterrent  influence  upon  the  devel- 
opment of  children  is  their  unfavorable  start  during  the  first  year. 
Unfortunately  many  mothers  cannot  supply  to  the  infant  the  requisite 
nourishment.  This  brings  us  to  the  matter  of  substitute  feeding, 
fraught  with  perplexities  and  uncertainties  in  the  most  competent 
hands,  and  with  dangers  and  disasters  in  the  hands  of  the  incompetent 
and  inefficient.  In  the  chapter  on  Substitute  Feeding  in  infants  their 
nutrition  is  considered  in  detail.  It  is  sufficient  to  remark  here  that 
nature  has  provided  for  the  baby  a  food  which  contains  the  nutritional 
elements,  fat,  sugar,  and  proteid,  in  fairly  definite  proportions  and  in 
peculiar  forms.  Success  in  substitute  feeding  depends  upon  our  ability 
to  supply  in  suitable  forms,  and  the  child's  ability  to  assimilate,  a  food 
containing  the  nutritive  elements  in  approximately  the  quantities 
found  in  human  milk.  An  exact  reproduction  of  mother's  milk  by  the 
use  of  cow's  milk  or  other  food  is,  of  course,  impossible.  We  can 
imitate  human  milk,  however,  with  sufficient  accuracy  to  make  accept- 
able and  sufficient  food  for  most  children  who  are  deprived  of  the  breast. 
After  the  nursing  or  the  bottle  age,  the  feeding  must  not  be  left  to  the 
family  judgment,  for  at  this  period  of  rapid  growth  suitable  nutrition  is 
most  important.  Left  to  the  family,  the  diet  during  the  second  year 
too  frequently  consists  of  milk,  which  in  large  cities  is  often  of  uncer- 
tain nutritive  value,  together  with  insufficiently  cooked  cereals,  boxed 
breakfast  foods,  bread-stuffs,  crackers,  and  cake — often  procured  at 
the  grocer's  or  baker's.  At  the  out-patient  departments  of  the  New 
York  Babies'  Hospital  and  the  New  York  Polyclinic  Medical  School, 
only  20  per  cent,  of  the  children  treated  who  are  over  one  year  of  age 
are  of  normal  development.  In  those  under  one  year  of  age,  only  35 
per  cent,  are  normal.     While  these  children  are  not  to  be  considered  as 


NUTRITION    AND    GROWTH  19 

representing  the  country  as  a  whole,  still  they  do  represent  a  large  part 
of  the  population  of  our  larger  cities.  These  children  are  the  offspring 
of  day-laborers,  drivers,  waiters,  and  small-wage  earners  generally. 
Such  children  were  fed  in  the  manner  above  described,  not  because  of 
poverty,  but  because  of  an  absence  of  the  slightest  knowledge  on  the 
part  of  the  parents  regarding  suitability  of  foods.  The  children  were 
not  hungry;  they  were  fed  to  satisfy  the  appetite;  but  when  that  was 
accomplished  the  parents  considered  their  duty  done.  To  feed  with  a 
definite  purpose — with  a  view  solely  to  the  physical  development  of 
their  children — had  never  entered  the  minds  of  the  parents,  yet  most  of 
them  could  read  and  write  and  possessed  a  fair  degree  of  general  intelli- 
gence. They  were  conversant  with  affairs  and  had  attended  the  public 
schools,  but  were  absolutely  untaught  as  to  how  they  should  live. 

Selection  and  Preparation  of  Food. — The  diet  during  this  period  of 
early  childhood  should  be  highly  nutritious,  and,  in  order  to  be  properly 
digested,  food  should  be  given  at  definite  intervals.  It  should  be  well 
cooked  and  properly  seasoned.  The  habit  of  allowing  children  to  eat 
between  meals  cannot  be  too  strongly  condemned.  It  not  only  spoils 
the  appetite  for  suitable  food  at  regular  hours,  causing  children  to  crave 
delicacies,  but  prevents  complete  digestion  and  assimilation.  The 
active  "runabout"  child  and  the  school-child  require  a  high  proteid 
diet.  This  should  consist  of  red  meat,  never  oftener  than  once  daily, 
poultry,  fish,  eggs,  milk,  butter,  cream,  whole-wheat  bread  and  cereals, 
such  as  oatmeal,  cracked  wheat,  cornmeal,  and  hominy.  For  the  sake 
of  variety  other  cereals  may  be  used.  Each  cereal  mentioned  should 
be  cooked  three  hours  the  day  before  using.  It  may  be  claimed  that 
the  prolonged  cooking  is  impossible  to  secure.  It  is  done,  however,  in 
dozens  of  families  under  my  professional  care.  Green  vegetables  and 
stewed  and  raw  fruits  are  important  adjuncts  to  the  dietary.  Dried 
peas,  beans,  and  lentils  in  the  form  of  a  puree  are  valuable  articles  of 
nutrition  because  of  their  large  percentage  of  vegetable  proteid,  and 
they  are  particularly  useful  in  children  with  a  rheumatic  tendency,  for 
whom  the  use  of  red  meat  must  be  curtailed. 

Fresh  Air — Doubtless  the  next  most  important  factor  after  food 
and  the  means  of  giving  it  is  good  au'.  It  is  a  just  criticism  of  the 
average  American  that  he  is  afraid  of  fresh  air,  not  only  by  night  but  by 
day.  Ventilation  is  one  of  the  most  difficult  features  of  a  child's 
management  with  which  I  have  had  to  deal.  Mothers  will  feed  the 
children  in  detail  according  to  instruction.  They  will  bathe  them  and 
follow  out  to  my  satisfaction  every  order  and  direction.  The  stumb- 
ling-block is  the  open  window.  If  the  mother  opens  it  as  du'ected, 
the  grandmother  or  some  other  member  of  the  family  appears  on  the 
scene  and  closes  it.  The  window-board  (p.  138)  and  other  means  of 
ventilation  on  the  market  have  their  uses.  The  window-board  in  my 
hands  has  been  most  satisfactory.  It  is  to  be  hoped  that  a  knowledge 
of  the  means  and  results  of  treating  tuberculosis  by  open-air  methods, 
and  the  recent  agitation  concerning  the  treatment  of  pneumonia  and 
other  infectious  diseases  along  similar  lines,  may  so  permeate  the  minds 


20  THE    PRACTICE    OF    PEDIATRICS 

of  the  masses  as  to  quiet  their  fears  regarding  dangers  of  outdoor 
air. 

In  my  own  experience  I  have  been  able  to  secure  an  ample  supply 
of  fresh  air  either  by  the  window-board,  already  referred  to,  or  the 
open  fireplace.  While  the  child  is  out  of  the  living-room  or  nursery, 
the  room  should  be  ventilated  by  opening  all  the  windows,  when  family 
conditions  allow,  the  nursery  always  being  aired  in  this  way.  The 
sleeping-room  should  always  be  aired  for  one  hour  before  the  child  is 
put  to  bed.  Indoor  airing  for  which  the  child  is  dressed  as  for  going 
out,  placed  in  his  carriage  or  cart,  and  wheeled  up  and  down  the  room 
for  an  hour  or  two  with  the  windows  wide  open  regardless  of  the 
weather,  is  most  satisfactory  in  treating  very  young  and  delicate  chil- 
dren, and  promoting  convalescence  from  illness.  On  inclement  days 
the  well  child  accustomed  to  his  daily  outing  will  be  greatly  benefited 
by  the  indoor  airing.  It  is  fully  appreciated  that  such  a  course  of 
management  is  impossible  in  many  households.  The  scheme  is  the 
ideal  one,  however,  and  should  be  followed  out  as  closely  as  possible. 

Bathing. — The  necessity  for  the  daily  bath  is  appreciated  and  acted 
upon  by  nearly  all  classes  of  society.  From  the  time  the  cord  falls 
and  the  cicatrix  forins,  the  well  infant  or  child  should  have  one  tub- 
bath  daily.     If  he  is  too  ill  for  the  tub,  he  is  not  too  ill  to  be  sponged. 

Work  and  Stress. — The  well  child  is  naturally  good-natured  and 
happy.  When  such  is  not  the  condition,  we  have  not  a  well  child  to 
deal  with.  Something  is  wrong.  Oftentimes  it  is  the  home  manage- 
ment. Adults  often  forget  that  exuberance  of  spirits  and  thoughtless- 
ness belong  to  childhood.  Persistent  child-nagging  becomes  a  habit 
with  many  parents  and  teachers ;  in  fact,  irritable  mothers  usually  have 
irritable  children.  Work  involving  strain,  whether  physical  or  mental, 
should  form  no  part  of  the  life  of  the  child.  In  our  modern  school 
system  the  forcing  process,  the  competitions,  the  giving  of  rewards  of 
merit,  are  all  pernicious  practices.  As  a  result  of  the  competitive 
system,  progress,  to  be  sure,  is  made  along  intellectual  lines,  but  at  the 
expense  of  the  physical;  and  what  does  intellectual  attainment  count 
for  in  a  weakly  or  diseased  body?  A  child  cannot  do  hard  mental  work, 
such  as  is  required  of  many  children  from  the  tenth  to  the  fifteenth 
year,  and  be  expected  at  the  same  time  to  develop  to  the  best  advantage 
physically.  The  appetite  and  digestive  powers,  the  capacity  for  taking 
and  assimilating  food,  are  diminished.  I  have  seen  the  result  in  hun- 
dreds of  cases.  On  the  streets  in  New  York  two  pictures  always  fill 
me  with  pity.  One  is  that  of  the  pale,  slender  school-girl  struggling 
home  with  a  load  of  books.  Such  a  child  who  came  to  me  recently 
had  11  text-book  studies  besides  piano  and  dancing  lessons!  When 
the  question  is  asked  the  child  or  the  parents  as  to  the  necessity  for  all 
this  work  and  worry  and  the  close  confinement  which  it  entails,  the 
reply  almost  invariably  is  that  all  the  girls  of  her  age  do  the  same  and 
she  does  not  want  to  be  behind.  The  other  picture  is  that  of  the  "  little 
mother" — a  pale,  wan,  tired  child  from  seven  to  twelve  years  of  age 
who  "minds  the  baby"  and  the  other  younger  members  of  the  house- 


MATERNAL    NURSING  21 

hold  while  their  mother  is  away  from  home  or  at  work.  Children  so 
abused  are  happily  growing  fewer,  owing  to  various  factors  which  need 
not  be  discussed.  It  is  needless  to  say  that  neither  type  of  girl  makes 
the  ideal  woman  or  mother  in  any  station  in  life.  The  condition  of 
boys  who  work  in  factories,  sweat-shops,  or  elsewhere  is  no  better. 
When  too  much  energy  is  expended  in  work,  it  cannot  go  to  the  build- 
ing of  a  strong,  normal  body.  The  State  is  the  loser  and  the  child  is 
robbed  of  his  birthright. 

It  is  the  duty  of  physicians  having  children  under  their  care  to 
explain  in  detail  to  parents  their  responsibility  as  regards  the  physical 
welfare  of  their  children.  Parents,  as  a  rule,  are  ignorant  concerning  a 
child's  management;  but  they  are  anxious  and  willing  to  do  the  best 
things  possible,  and  will  carry  out  suggestions  if  we  take  the  trouble  to 
enlighten  them  as  to  their  errors. 

MATERNAL  NURSING 

Writers  on  this  subject  are  very  prone  to  state  that  the  ability  of  the 
mother,  particularly  among  the  well-to-do,  to  fulfil  this  most  important 
function  is  surely  decreasing.  This  may  have  been  a  true  statement 
fifteen  or  twenty  years  ago;  at  the  present  time,  however,  I  am  sure  it 
is  erroneous.  In  my  own  medical  life  I  have  seen  a  change  for  the 
better,  particularly  during  the  past  fifteen  years.  The  young  mother 
of  today  is  better  able  to  nurse  her  offspring  than  was  her  sister  fifteen 
or  twenty  years  ago.  I  attribute  this  to  the  fact  that  the  youth  of  the 
present  day  are  more  vigorous,  more  nearly  normal  individuals  than 
were  those  of  an  earlier  date.  The  inability  to  perform  the  nursing 
function  so  that  it  will  be  successful  has  always  been  attributed  to  the 
mother  ipse.  This,  I  think,  is  an  error.  A  child  born  with  a  generally 
enfeebled  vitality,  keenly  feels  any  slight  abnormality  in  the  milk,  or 
may  not  be  able  to  digest  perfectly  normal  milk;  in  either  event,  the 
milk  disagrees  and  the  nursing  is  discontinued.  Not  every  breast-milk 
for  two  or  three  weeks  after  parturition  is  ideal,  as  I  have  found  by  the 
examinations  of  hundreds  of  specimens.  Breast-milk  during  the  first 
two  or  three  weeks  of  the  infant's  life  is  produced  under  unfavorable 
conditions  which  do  not  indicate  the  possibilities  of  the  breast  as  a 
secreting  organ.  Early  nursing  following,  as  it  does,  upon  the  stress 
of  confinement,  is  not  indicative  of  what  may  be  possible  later  when  the 
customary  life  and  daily  habits  are  resumed.  Repeatedly  I  have  found 
a  very  high  fat  or  a  high  proteid,  or  both,  entirely  corrected  after  the 
first  week  or  two,  without  interference.  This  condition  at  the  time  was 
considered  sufficiently  serious  to  warrant  the  discontinuance  of  nursing 
on  the  part  of  a  weakly  infant,  while  in  a  vigorous  infant  it  would  be 
entirely  ignored. 

The  change  which  enables  more  mothers  successfully  to  nurse  their 
infants  is  due  to  two  causes — more  vigorous  fathers  and  mothers  and 
more  vigorous  offspring.  The  more  normal  the  mother,  the  better 
able  is  she  to  perform  this  normal  function.     That  this  is  the  case  is 


22  THE    PRACTICE    OF    PEDIATRICS 

due,  I  believe,  to  the  fact  that  growing  girls  and  young  women  are 
leading  more  hygienic  lives  than  formerly.  The  making  of  golf, 
bicycle  and  horseback  riding,  boating,  and  automobiling  popular  and 
fashionable — in  short,  the  taking  of  girls  out-of-doors  and  keeping  them 
there  a  considerable  portion  of  the  day — has  worked  a  marvelous 
change  for  the  better,  both  physically  and  mentally.  A  neurotic 
mother  makes  the  poorest  possible  milk-producer.  Proportionate  to 
the  population,  there  are  fewer  neurasthenics  among  the  young  women 
today  than  there  were  twenty  years  ago,  and  there  will  be  still  fewer 
twenty  years  hence.  At  the  present  time  the  timid,  retiring  young 
woman  of  the  neurasthenic  type  is  not  popular  in  her  set.  It  is  for- 
tunate for  the  future  of  the  human  race,  at  least  for  that  portion  which 
resides  in  the  United  States,  that  the  young  woman  has  transferred  her 
allegiance  from  the  crochet  and  embroidery  needle  to  out-of-door  sports. 
It  may  be  said  that  our  argument  holds  only  with  the  wealthy  or  the 
well-to-do.  Imitation  is  one  of  the  strongest  characteristics  of  the 
human  race,  and  this  tendency  in  America  to  outdoor  hygienic  living 
pervades  all  classes.  Saturday  half-holidays,  and  the  excursions  and 
outings  afforded  by  reduced  rates  in  transportation,  are  much  more 
popular  than  they  were  twenty  years  ago.  Food  is  better  selected  and 
better  prepared,  owing  to  increased  knowledge  on  the  part  of  the  people 
as  to  what  constitutes  proper  nutrition.  These  are  facts,  in  spite  of  the 
sensational  novelists  and  magazine- writers. 

A  feature  which  marks  an  important  advance  in  the  right  direction 
is  the  establishment  of  a  department  in  dietetics  and  food  economics 
in  the  New  York  Training  School  for  Teachers.  The  Dean,  Dr.  James 
E.  Russell,  in  establishing  this  course  is  producing  benefits  which  per- 
haps are  more  far-reaching  than  he  realizes.  The  students  are  taught 
food  values,  food  preparation,  and  food  economics,  the  science  of  pro- 
viding for  a  given  amount  of  money  the  most  nutritious  food  in  its  most 
attractive  form.  Of  the  hundreds  of  teachers  sent  out  from  this  insti- 
tution every  year  to  take  their  places  of  usefulness  as  instructors  of  the 
young  in  all  portions  of  the  country,  each  has  learned  something  of 
food  values,  and,  better  still,  each  has  been  impressed  with  the  impor- 
tance, to  a  growing  child,  of  proper  nutrition,  without  which  the  best 
possible  type  of  adult  cannot  be  produced.  As  a  result  of  such  in- 
struction these  teachers  will  be  of  far  greater  service  in  their  fields  of 
labor;  for  not  only  can  they  teach  what  is  laid  down  in  the  books,  but, 
what  is  equally  if  not  more  important,  they  are  competent  to  teach 
those  under  their  care  so  to  live  as  to  attain  proper  growth,  following 
out  the  maxim  of  Herbert  Spencer  that  "  the  first  requisite  for  success 
in  life  is  to  be  a  good  animal ;  and  to  be  a  nation  of  good  animals  is  the 
first  condition  of  national  prosperity."  It  may  be  thought  that  we 
have  wandered  far  from  our  subject, — maternal  nursing, — but  such 
is  not  the  case;  for  conditions  which  relate  even  remotely  to  this  im- 
portant function  demand  our  respectful  consideration.  The  food 
and  care  of  the  growing  girl  have  the  most  intimate  bearing  upon  her 
future  life,  and  if  she  is  to  be  called  upon  to  perform  the  most  impor- 


MATERNAL    NURSING  23 

tant  function  of  womanhood,  she  surely  has  the  right  to  demand  that 
she  receive  during  her  girlhood  proper  preparation,  which  heretofore 
has  too  often  been  denied  her. 

The  family  physician  does  not,  in  a  great  majority  of  instances,  fulfil 
his  function,  or  extend  his  field  of  usefulness  to  its  full  capacity,  his 
conception  of  duty  too  often  including  only  the  care  of  the  sick.  Un- 
sought advice  concerning  the  feeding  and  daily  habits  of  a  child's  life, 
I  find  is  usually  welcomed  and  appreciated  by  the  parents.  In  practi- 
cally every  instance,  according  to  my  observation,  errors  in  a  child's 
management  are  due  to  ignorance.  Parents,  no  matter  what  their 
station  in  life,  are  glad  to  do  what  is  for  the  best  interests  of  their 
children  when  the  situation  is  made  clear  to  them.  It  is  our  duty  to 
take  parents  into  our  confidence  and  explain  to  them  the  reasons  for  the 
line  of  action  advised.  When  they  appreciate  the  reason  for  certain 
procedures,  I  find  that  they  are  far  more  apt  to  follow  them.  I  am 
confident,  from  observations  upon  many  cases,  that  if  I  could  have  the 
physical  direction  of  ten  average  girls  in  any  station  in  life,  provided  that 
they  could  have  the  benefit  of  fresh  air  and  good  food  from  infancy  to 
adolescence,  successful  nursing  mothers  could  be  made  out  of  eight  of 
them.  Certain  rules  of  life  having  a  direct  bearing  on  nursing  lead  us 
nearer  the  ideal  and  may  enable  one  who  otherwise  could  not  nurse  her 
child  to  do  so  successfully.  These  requirements,  it  will  be  seen,  are  laid 
along  common  sense  lines  and  cause  no  hardship  or  mental  distress,  one 
of  the  chief  requirements  of  a  nursing  woman  being  that  she  shall  be 
mentally  normal. 

Few  functions  with  which  we  are  called  to  deal  are  so  variable  and 
uncertain  as  the  production  of  breast-milk.  Breast-milk  is  one  of  the 
most  precious  substances.  It  is  invaluable — unless  we  can  put  a  value 
on  human  life.  The  most  successful  nursing  age  is  between  the  twen- 
tieth and  thirty-fifth  years.  I  have,  however,  seen  successful  nursing 
carried  on  in  a  girl  of  fourteen,  in  a  woman  of  fifty-two,  and  in  the 
much  abused  society  girl,  while  I  have  seen  it  fail  absolutely  in  peasant 
women  fresh  from  the  fields  of  Hungary  and  Bohemia.  I  have  seen 
those  whose  nursing  at  first  was  most  unsatisfactory  develop  into  per- 
fect nurses. 

Some  mothers  will  be  able  to  carry  on  the  nursing  for  only  two 
months;  others,  three,  five,  seven,  or  nine  months.  In  my  experience 
in  both  out-patient  and  in  private  practice  it  is  extremely  rare  for  the 
breast  milk  to  be  sufficient  for  a  child  after  the  ninth  month.  A  most 
unusual  record  in  nursing  is  that  of  an  Italian  woman  who  nursed 
uninterruptedly  and  successfully  three  infants  of  her  prolific  employer. 
The  first  two  children  were  each  nursed  for  one  year,  the  third  child 
for  ten  months.  Even  then  the  supply  had  not  diminished,  but 
nursing  was  discontinued  because  of  illness  of  wet  nurse. 

The  following  may  be  laid  down  as  nursing  axioms : 

A  diet  similar  to  that  which  the  mother  was  accustomed  to  before 
the  advent  of  motherhood  should  be  taken. 

There  should  be  one  bowel  evacuation  daily. 


24  THE    PRACTICE    OF    PEDIATRICS 

From  three  to  four  hours  daily  should  be  spent  in  the  open  air  in 
exercise  which  does  not  fatigue. 

At  least  eight  hours  out  of  every  twenty-four  should  be  given  to 
sleep. 

There  should  be  absolute  regularity  in  nursing. 

There,  should  be  no  worry  and  no  excitement. 

The  mother  should  be  temperate  in  all  things. 

The  Diet. — Many  times,  when  consulted  by  nursing  mothers  be- 
cause the  nursing  was  unsuccessful  or  a  partial  failure,  I  have  found 
that  their  diet  had  been  restricted  to  an  extreme  degree.  To  put  on  a 
greatly  restricted  diet  a  robust  young  mother  who  has  always  eaten 
bountifully  of  a  generous  variety  of  foods  is  one  of  the  best  means  of 
curtailing  the  quantity  and  lowering  the  quality  of  her  milk-supply. 
When  asked  to  prescribe  a  diet  I  tell  such  mothers  to  eat  as  they  were 
accustomed  to  before  the  advent  of  pregnancy  and  motherhood.  That 
this  particular  vegetable  or  that  particular  fruit  should  be  forbidden  on 
general  principles  is  a  fallacy.  Food  that  the  patient  can  digest  with- 
out inconvenience  is  a  safe  food  so  far  as  the  nursing  is  concerned,  as 
may  readily  be  determined  in  any  given  case.  For  certain  individuals, 
however,  a  plain,  more  or  less  restricted  diet  is  desirable.  This  must 
be  remembered  in  the  management  of  the  wet-nurse  (p.  33).  Many  a 
wet-nurse  who  has  been  carefully  selected,  and  who  to  the  best  of  our 
judgment  should  prove  satisfactory,  utterly  fails  in  a  few  days  to  fulfil 
the  duties  of  the  office  for  which  she  was  chosen.  In  not  a  few  in- 
stances the  failure  is  due  to  a  very  full  diet  of  unusual  articles  of  food, 
the  existence  of  which,  in  many  instances,  she  never  dreamed.  Indi- 
gestion and  constipation  follow,  both  the  nurse  and  the  baby  are  made 
ill,  and  the  woman's  usefulness  ceases.  A  woman  who  has  lived  and 
kept  well  on  the  diet  and  food  found  in  the  home  of  the  laboring  man, 
whether  in  the  city  or  country,  will  make  a  far  better  wet-nurse  on  this 
diet  than  if  she  indulges  in  food  to  which  she  is  entirely  unaccustomed. 
In  general,  the  diet  of  a  nursing  mother,  then,  should  be  that  to  which 
she  has  been  accustomed. 

Nursing  is  a  perfectly  normal  function,  and  a  woman  should  be  per- 
mitted to  carry  it  out  along  only  natural  lines.  Inasmuch  as  there 
are  two  lives  to  be  provided  for  instead  of  one,  more  food,  particularly 
of  a  liquid  character,  may  be  taken  than  the  mother  may  have  been 
accustomed  to.  It  is  my  custom  to  advise  that  milk  be  given  freely. 
A  glass  of  milk  may  be  taken  in  the  middle  of  the  afternoon  and  eight 
ounces  of  milk  with  eight  ounces  of  oatmeal  or  cornmeal  gruel  at  bed- 
time, if  it  does  not  disagree  with  the  patient.  Our  only  evidence  that  a 
food  is  not  disagreeing  is  the  condition  of  the  digestion.  When  any 
article  of  food  disagrees  with  the  mother,  or  if  she  is  convinced  that  it 
disagrees,  whether  or  not  such  is  really  the  case,  the  food  should  be  dis- 
continued. In  a  general  way,  milk  in  quantities  not  over  one  quart 
daily,  eggs,  meat,  fish,  poultry,  cereals,  green  vegetables,  and  stewed 
fruit  constitute  a  basis  for  selection.  The  method  of  preparation  for 
the  different  meals  is  not  arbitrary. 


MATERNAL    NURSING  25 

The  Bowel  Function.^ — A  very  important  and  often  neglected  matter 
in  relation  to  nm'sing  is  the  condition  of  the  bowels.  There  must  be 
one  free  evacuation  daily.  For  the  treatment  of  constipation  in  nurs- 
ing women  I  have  used  different  methods  in  many  cases.  The  dietetic 
treatment  does  not  promise  much.  For  here,  again,  manipulation  of 
the  diet  may  interfere  with  the  milk  production.  Three  methods  are 
open  to  use — massage,  local  measures,  and  drugs.  Massage  is  available 
in  comparatively  few  cases.  Local  measures  consist  in  the'  use  of 
enemas  or  suppositories.  Every  nursing  woman  under  my  care  is  in- 
structed to  use  an  enema  at  bedtime  if  no  evacuation  of  the  bowels  has 
taken  place  during  the  previous  twenty-four  hours.  Many  out- 
patients, in  whom  constipation  is  very  prevalent,  indulge  in  excessive 
tea-drinking,  often  taking  from  one  to  two  gallons  of  tea  daily.  In 
treating  such  patients  where  an  absolute  discontinuance  of  the  tea- 
drinking  is  often  impossible  and  not  absolutely  necessary,  I  usually 
allow  two  cups  a  day.  For  a  laxative  in  such  cases  and  in  many  others, 
a  capsule  of  the  following  composition  has  served  well : 


I^     Extract!  belladonnse gr. 

Extracti  nucis  vomicae gr. 


Extract!  cascarae  sagradae gr.  v 

M.  et.  ft.  capsula  No.  i. 

Sig. — To  be  taken  at  bedtime. 

The  amount  of  the  cascara  sagrada  may  be  varied  as  the  case  may 
require.  In  not  a  few  instances  I  have  found  it  necessary  to  give  two 
capsules  a  day  in  order  to  produce  the  desired  result.  Neither  the 
belladonna,  the  nux  vomica,  nor  the  cascara  appears  to  have  any  ap- 
preciable effect  on  the  child. 

Air  and  Exercise. — Outdoor  life  and  exercise  are  not  only  as  desir- 
able here  as  they  are  under  all  other  conditions,  but  to  the  nursing 
woman,  with  her  added  responsibility,  they  are  doubly  valuable.  In 
order  to  get  the  best  results,  exercise  or  work  should  so  be  adjusted  as 
not  to  reach  the  point  of  fatigue.  The  mother  whose  nights  are  dis- 
turbed should  be  given  the  benefit  of  a  midday  rest  of  an  hour  or  two. 
She  should  have  at  least  eight  hours'  sleep  out  of  every  twenty-four. 
Certain  annoyances,  anxieties,  and  worries  are  inseparable  from  the 
life  of  every  child-bearing  woman.  It  should  be  our  duty,  however,  to 
explain  to  the  mother  and  to  other  members  of  the  family  that  an 
important  element  in  satisfactory  nursing  is  a  tranquil  mind.  During 
the  lactation  period  she  should  be  spared  all  unnecessary  care  and  petty 
annoyances. 

Regularity  in  Nursing. — The  breast  which  is  emptied  at  definite 
intervals  invariably  functionates  better  than  does  one  which  is  not,  not 
only  as  regards  the  quantity,  but  also  the  quality,  of  the  milk;  so  that 
system  in  breast-feeding  is  almost  as  essential  to  milk-production  as 
to  its  digestion  and  assimilation. 

After  it  is  demonstrated  that  the  nursing  is  progressing  satisfac- 
torily, as  proved  by  the  satisfied,  thriving  child,  I  begin  with  one  bottle- 
feeding  daily.     The  advisability  of  this  is  obvious:  in  case  of  illness  of 


26  THE    PRACTICE    OF    PEDIATRICS 

the  mother,  if  she  is  called  away  from  home,  or  if,  for  any  reason,  the 
child  cannot  have  the  breast,  the  feeding  is  provided  for.  Another 
advantage  of  this  provision  is  that  it  gives  the  mother  needed  freedom 
from  restraint.  She  is  thus  enabled  to  have  the  benefit  of  a  change  of 
scene.  Amusements  and  recreations  which  the  invariable  nursing 
period  denies  her  can  be  indulged  in.  As  a  result  of  this  greater  free- 
dom she  is  able  to  supply  better  milk  and  to  continue  nursing  longer 
than  if  tied  continually  to  the  baby,  no  matter  how  fond  of  the  infant 
she  may  be. 

Frequency  of  Nursing. — From  birth  until  the  third  month  seven 
nursings  in  twenty-four  hours  are  allowed  as  follows:  6  a.  m.,  9  a.  m., 
12  M.,  3  p.  M.,  6  p.  M.,  10  p.  M.,  2  A.  M.  From  the  third  to  the  completion 
of  the  six  month,  six  nursings  as  follows:  6  a.  m.,  9  a.  m.,  12  m.,  3  p.  m., 
6  p.  M.,  10  p.  M.  After  the  sixth  month,  and  in  large  strong  children 
after  the  fifth  month,  five  nursings  in  twenty-four  hours,  as  follows: 

6  A.  M.,  10  A.  M.,  2  p.  M.,  6  p.  M.,  10  p.  M. 

Giving  of  Water. — From  one-half  to  one  ounce  of  a  1  per  cent, 
solution  of  milk-sugar  shpuld  be  given  the  infant  every  three  hours 
until  the  milk  appears  in  the  breast.  Otherwise  there  will  be  unneces- 
sary loss  in  weight  and  perhaps  a  high  degree  of  fever  due  to  inanition. 

If  the  child  is  restless  and  uncomfortable,  it  is  safe  to  conclude  that 
he  is  thirsty;  one  ounce  of  the  sugar  water  will  usually  satisfy  him. 
With  the  commencement  of  nursing,  the  baby  should  be  accustomed  to 
getting  his  food  at  regular  intervals. 

Signs  of  Successful  Nursing. — The  normal  infant  shows  a  gain  of 
not  less  than  four  ounces  weekly.  This  is  the  minimum  weekly  gain 
which  may  safely  be  allowed.  When  a  nursing  baby  remains  station- 
ary in  weight  or  makes  a  gain  of  but  two  or  three  ounces  a  week,  it 
means  that  something  is  wrong,  and  the  defect  will  usually,  but  not 
invariably,  be  found  in  the  milk-supply.  When  the  baby  is  nursed  at 
proper  intervals  and  the  supply  of  milk  is  ample  and  of  good  quality,  he 
is  satisfied  at  the  completion  of  the  nursing.  Under  three  months  of 
age  he  falls  asleep  after  ten  or  twenty  minutes  at  the  breast.  When 
the  nursing  period  again  approaches,  he  becomes  restless  and  unhappy, 
crying  lustily  if  the  nursing  is  delayed.  When  the  breast  is  offered, 
he  takes  it  greedily.  The  stools  are  yellow  and  number  from  two  to 
three  daily.  The  weekly  gain  in  weight  under  such  conditions  is  usually 
from  six  to  eight  ounces. 

Signs  of  Unsuccessful  Nursing. — Theoretically,  every  normal  breast 
infant  should  be  a  thriving,  well  baby.  That  such  is  not  the 
case,  is  an  unfortunate  fact.  The  standard  established  for  a  well  baby 
is  not  upheld.  When  the  supply  of  milk  is  scanty  the  child  remains 
long  at  the  breast  and  cries  when  he  is  removed.  He  shows  signs  of 
hunger  before  the  nursing  hour  arrives.  A  cause  of  failure  in  breast- 
feeding, and  probably  the  most  frequent  cause,  is  a  scanty  milk-supply. 
The  chief  nutritional  elements  in  mother's  milk  are  fat,  3  to  4  per  cent. ; 
sugar,  7  per  cent. ;  proteid,  1.5  per  cent.  Failure  may  be  due  to  a  marked 
disproportion   of   these   elements,   which  may  cause  sufficient   indi- 


MATERNAL    NURSING  '■  ^7 

gestion  and  resulting  loss  in  weight  to  necessitate  a  discontinuance  of 
nursing.  Thus  there  may  be  a  high  fat — from  5  to  6  per  cent. ;  or  very- 
low  fat — from  1  to  1.5  per  cent.  In  the  high-fat  cases  there  is  usually 
diarrhea  with  green,  watery  stools.  The  child  strains  a  great  deal  and 
there  are  green  stains  on  many  of  the  napkins.  In  high-fat  cases  there 
is  also  regurgitation  or  vomiting  of  sour  material.  The  fat-globules 
may  readily  be  made  out  if  the  vomited  material  is  placed  under  a  low- 
power  microscope.  Low  fat  means  deficient  nourishment  and  may 
cause  constipation.  Sugar  is  rarely  a  cause  of  trouble  in  nursing 
babies.  It  seldom  varies,  ranging  from  5  to  7  per  cent,  in  the  great 
majority  of  breast- milks.  Young  children,  further,  have  a  marked 
toleration  for  sugar.  Protein  constitutes  one  of  the  most  important 
constituents  of  mother's  milk.  Like  the  fat,  the  proteid  may  be  so 
decreased  that  nutritional  disorder  may  be  induced  in  the  patient,  or  it 
may  be  very  much  increased,  the  latter  condition  being  usually  the 
cause  of  colic  or  constipation  in  otherwise  healthy  nursing  infants. 
The  milk  may  contain  the  normal  percentage  of  fat,  sugar,  and  proteid, 
but  be  scanty  in  amount.  Instead  of  the  four  or  five  ounces  to  which 
the  child  is  entitled,  he  may  get  but  one  or  two  ounces.  Whether  or 
not  the  quantity  is  sufficient,  may  be  determined  by  weighing  the  baby 
before  and  after  each  nursing  for  twenty-four  hours.  One  ounce  of 
breast-milk  weighs  practically  one  ounce  avoirdupois.  The  quality  or 
strength  is  determined  by  an  examination  of  the  milk  itself  (p.  32). 
The  quantity  is  determined  by  noting  the  weight  of  the  child,  wearing 
the  same  clothing,  before  and  after  nursing.  By  nursing  for  fifteen 
minutes,  a  child  under  four  v/eeks  of  age  should  gain  from  2  to  3  ounces ; 
four  to  eight  weeks  of  age,  3  to  4  ounces;  eight  to  sixteen  weeks  of  age, 
4  to  5  ounces ;  sixteen  to  twenty-four  weeks  of  age,  5  to  6  ounces ;  six  to 
nine  months  of  age,  6  to  8  ounces ;  nine  to  twelve  months  of  age,  8  to  9 
ounces.     Of  course,  arbitrary  limits  cannot  be  fixed  as  to  the  quantity. 

Stationary  weight  or  loss  in  weight,  with  a  dissatisfied  child,  usually 
means  defects  in  quantity  of  milk,  which  are  readily  proved  by  the 
weighing.  To  be  fed  at  the  breast  may  also  cause  the  child  to  suffer 
from  an  excess  of  good  milk,  in  which  event  there  will  be  vomiting  or 
regurgitation,  usually  associated  with  colic.  When  this  overfeeding 
continues,  dilatation  of  the  stomach  develops,  vomiting  becomes  habit- 
ual, the  child  loses  in  weight,  the  breast-milk  is  said  not  to  agree,  and 
often,  unfortunately,  the  baby  is  weaned.  This  has  been  the  outcome 
in  scores  of  cases.  When  there  is  habitual  vomiting  and  colic  in  a 
nursing  baby,  two  things  are  to  be  done — the  baby  must  be  weighed 
before  and  after  nursing,  and  the  milk  must  be  examined. 

I  have  repeatedly  treated  children  for  indigestion  who  were  entirely 
relieved  by  shortening  the  nursing  period.  Weighing  the  baby  at 
intervals  of  from  three  to  five  minutes  and  noting  the  gain  has  shown 
that  the  three  or  four  ounces  which  may  represent  the  child's  stomach 
capacity  were  obtained  in  two,  three,  or  five  minutes,  the  excess  which 
the  child  took  over  this  amount  being  the  cause  of  his  trouble.  From 
a  free,  full  breast  a  vigorous  nurser  will  take  one  ounce  in  one  minute. 


28  THE    PRACTICE    OF    PEDIATRICS 

When  the  nursing  "gait"  is  estabhshed,  a  child  should  be  kept  up  to 
the  schedule.  There  are  few  more  pernicious  teachings  than  that  a 
baby  should  be  allowed  to  nurse  when  he  wants  to  and  as  long  as  he 
wants  to.  The  idea  that  a  nursing  infant  will  take  no  more  than  is 
good  for  him  is  the  fruit  of  inexperience.  Recently  a  mother  consulted 
me  in  regard  to  giving  her  one-month-old  baby  the  bottle,  as  he  had 
many  green  stools,  cried  a  great  part  of  his  waking  hours,  and  weighed 
but  a  few  ounces  more  than  at  birth.  Her  milk  was  supposed  to  be 
"too  strong"  for  the  child.  An  examination  of  the  breast  and  a  talk 
with  the  mother  satisfied  me  that  the  breast-milk  was  not  at  fault. 
An  examination  of  the  milk  proved  it  to  be  good  average  milk,  con- 
taining 3.5  per  cent,  fat,  6  per  cent,  sugar,  1.45  per  cent,  proteid.  A 
one  day's  test  by  weighing  was  instituted.  The  infant  was  allowed  to 
nurse  one  minute  and  rest  one  minute.  During  the  resting  period  he 
was  weighed.  In  this  way,  it  was  found  that  in  three  minutes  he 
got  from  3  to  33-^  ounces  of  milk.  The  nursing  was  then  reduced  to 
three  minutes  on  one  breast  and  five  minutes  on  the  other,  which  was 
the  "slower"  breast.  Thereupon  every  sign  of  indigestion  promptly 
disappeared,  the  stools  became  normal,  and  the  infant  made  a  satis- 
factory gain  in  weight  of  one  ounce  daily. 

The  quantity  may  be  suitable  for  the  age,  the  child  may  not  vomit 
or  show  a  sign  of  indigestion,  and  yet  may  not  thrive.  In  such  a  case 
an  examination  or  repeated  examinations  of  the  milk  at  intervals  of 
two  or  three  days  will  usually  show  that  it  is  poor,  below  the  normal 
perhaps  in  both  fat  and  proteid. 

Signs  of  Insufficient  Nursing. — The  baby  remains  long  at  the 
breast,  perhaps  one-half  to  three-quarters  of  an  hour.  When  removed, 
he  is  restless  and  uncomfortable.  After  a  short  time,  in  an  hour  or  less, 
he  is  very  hungry  and  demands  frequent  nursings  day  and  night. 

Management  of  Abnormal  Milk  Conditions.^ — When  it  is  found 
that  the  breast-milk  is  too  strong  or  too  weak,  or  when  the  normal 
ratios  of  fat,  sugar,  and  proteid  are  not  maintained,  it  may  be  possible 
to  increase  or  diminish  the  milk  strength.  When  desirable,  it  may 
also  be  possible  to  increase  either  the  fat  or  the  proteid.  The  heavy 
milk  will  usually  be  found  in  mothers  who  are  robust,  who  eat  heartily, 
and  who  take  but  little  exercise.  In  such  a  case,  the  prescribing  of  a 
plain  diet,  allowing  red  meat  but  once  a  day,  discontinuing  the  malt 
liquors  or  wine, — which  it  will  often  be  found  that  the  mother  is  taking, 
— and  directing  that  she  walk  a  mile  or  two  a  day,  will  frequently 
bring  the  milk  to  digestible  proportions.  In  some  cases,  however,  this 
will  not  be  successful,  and  the  colic,  constipation,  and  vomiting  may 
continue,  even  though  the  quantity  obtained  at  each  nursing  is  within 
normal  limits.  In  some  instances  it  will  be  impossible  to  change  the 
mode  of  the  mother's  life,  except  perhaps  in  the  discontinuance  of  al- 
cohol. When  such  conditions  prevail,  the  mother's  milk  may  be  modi- 
fied by  giving  from  one-half  to  one  ounce  of  boiled  water  or  plain  bar- 
ley-water before  each  nursing.  This  is  a  procedure  to  which  I  fre- 
quently resort.     One  teaspoonful  of  lime-water  added  to  one  ounce  of 


MATERNAL    NURSING  29 

water  before  each  nursing  has  made  the  breast-milk  agree  when  other- 
wise breast-feeding  would  have  been  impossible.  When  the  milk  is 
deficient  both  in  fat  and  proteid,  a  diet  composed  largely  of  red  meat, 
poultry,  fish,  rye  bread,  or  whole-wheat  bread,  oatmeal,  cornmeal, 
with  two  or  three  pints  of  milk  daily,  will  often  be  followed  by  an 
increase  both  in  fat  and  proteid.  The  use  of  alcohol  in  moderate 
amounts,  in  the  form  of  malt  liquors  or  wine,  will  usually  increase  the 
fat.  I  have  frequently  seen  it  advance  2  per  cent,  in  from  two  to  three 
days.  Disappointments  in  improving  the  quantity  or  quality  of  the 
breast-milk,  however,  are  frequent. 

In  addition  to  the  one  bottle  which,  for  reasons  above  mentioned, 
is  given  early  in  the  child's  life,  I  find  it  necessary  at  the  seventh  month 
to  add  an  extra  bottle  or  two.  Usually  at  this  time  the  proteid  in 
human  milk  begins  to  diminish  in  quantity,  and  as  this  is  the  most 
important  nutritional  element,  an  insufficient  quantity  at  this  rapidly 
growing  period  of  life  is  of  no  little  importance.  At  the  twelfth 
month,  with  very  few  exceptions,  my  nursing  babies  are  weaned  from 
necessity.  At  this  age  exclusive  breast-nursing,  if  one  would  consider 
the  best  interests  of  the  child,  is  practically  out  of  the  question.  Out  of 
many  thousands  of  cases  I  recall  but  one  instance  where  a  mother  was 
able  successfully  to  nurse  her  child  after  the  twelfth  month.  This 
remarkable  woman,  a  mother  of  six  children,  had  nursed  every  one  of 
them  exclusively  up  to  the  fifteenth  or  the  eighteenth  month. 

Mixed  Feeding. — With  a  diminution  in  the  amount  of  milk  secreted, 
the  breast-milk  must,  of  course,  be  supplemented  by  modified  cow's 
milk.  This  method  of  feeding  is  usually  successful.  If  the  mother  of 
a  four-months '-old  baby  can  satisfactorily  nurse  him  three  -times  in 
twenty-four  hours,  he  may  be  given,  in  addition,  two  or  three  bottle- 
feedings,  supplementing  the  mother's  milk.  It  is  best,  when  using 
mixed  feedings  to  alternate  the  breast  and  the  bottle.  The  modified 
milk  strength  should  be  that  which  is  suitable  for  the  average  child  of 
the  same  age.  (See  Infant-Feeding,  p.  58.)  In  beginning  the  use  of 
cow's  milk,  however,  it  must  be  remembered  that  at  first  a  weaker 
strength  must  be  used  than  the  child  will  require  for  growth,  this 
weaker  food  being  necessary  in  order  gradually  to  accustom  the  infant 
to  the  change.  If  too  strong  a  cow's-milk  mixture  is  given  at  first,  it 
will  be  very  apt  to  disagree,  causing  colic  and  vomiting.  Later,  when 
the  child  has  become  accustomed  to  the  new  food,  a  stronger  mixture 
may  be  given.  When  a  mother  cannot  give  her  infant  at  least  two 
satisfactory  breast-feedings  daily,  it  is  advisable  to  wean  the  child. 
In  infants  under  three  months  of  age,  it  may  be  advisable  to  supple- 
ment the  individual  nursings.  If  the  child  requires  four  ounces  at  a 
feeding,  and  if  we  find  by  several  weighings  before  and  after  nursings, 
that  the  breast  capacity  is  but  two  ounces,  an  additional  two  ounces 
may  be  given  by  the  bottle  at  the  completion  Of  the  nursings.  Follow- 
ing out  this  scheme  I  have  been  able  to  establish  entire  breast  feedings. 

Maternal  Conditions  Under  Which  Nursing  is  Forbidden. — When 
the  mother  has  tuberculosis  in  any  of  its  various  forms  or  manifesta- 


30  THE    PRACTICE    OF    PEDIATRICS 

tions,  whether  it  involves  the  glands,  the  joints,  or  the  lungs,  breast- 
feeding is  to  be  forbidden.  In  epilepsy  and  syphilis  nursing  is  likewise 
forbidden.  In  nephritis  and  malignant  disease  of  any  nature,  and  in 
chorea,  nursing  should  be  discontinued.  Women  who  are  rapidly 
losing  weight  should  not  be  allowed  to  continue  nursing  their  infants. 
In  case  of  serious  illness  of  any  nature,  such  as  typhoid  fever,  pneu- 
monia, or  diphtheria,  and  upon  the  advent  of  pregnancy,  nursing 
should  be  terminated. 

Care  of  the  Breasts  during  Weaning. — When  the  breast-feeding 
is  carried  on  the  usual  length  of  time, — from  nine  to  twelve  months, — 
the  process  of  weaning  ordinarily  causes  little  or  no  discomfort.  All 
that  is  usually  required  is  to  press  out  enough  of  the  milk  to  relieve 
the  patient  as  often  as  the  breast  becomes  painful,  which  may  not  be 
more  than  two  or  three  times  a  day.  When  the  weaning  is  necessarily 
abrupt,  no  little  discomfort  may  result.  If  there  is  a  free  flow  of  milk, 
which  is  apt  to  be  the  case  when  the  weaning  must  take  place  in  the 
early  nursing  period,  tightly  bandaging  the  breasts  is  required.  When 
localized  hardened  areas  occur  in  the  glands,  they  should  be  massaged 
until  softened,  and  the  bandage  reapplied  and  worn  until  the  secretion 
ceases.  When  the  weaning  can  be  accomplished  more  gradually,  the 
infant  should  have  one  less  nursing  every  second  or  third  day  until 
only  two  are  given  daily.  After  this  has  been  practised  for  one  week, 
nursing  can  be  discontinued.  In  cases  where  sudden  weaning  is  re- 
quired, a  saline  laxative,  such  as  citrate  of  magnesia  or  Rochelle  salts, 
should  be  given  every  day  for  five  days — sufficient  to  produce  two  or 
three  watery  evacuations  daily.  In  the  meantime  the  mother  should 
abstain  from  fluids  of  all  kinds  up  to  the  point  of  positive  discomfort. 

Conditions  Which  may  Temporarily  Produce  an  Unfavorable 
Effect  upon  the  Breast-milk,  but  not  Necessitate  the  Discontinuance 
of  Nursing. — The  advent  of  the  first  menstruation  period  particularly, 
and  in  some  cases  the  beginning  of  every  menstruation  period,  is  at- 
tended with  an  attack  of  colic  or  indigestion  in  the  child.  Such  at- 
tacks, however,  rarely  necessitate  the  discontinuance  of  the  nursing 
even  for  a  single  day. 

Factors  influencing  the  mental  condition  of  the  mother,  such  as 
anger,  fright,  worry,  shock,  distress,  sorrow,  or  the  witnessing  of  an 
accident,  may  affect  the  milk  secretion  sufficiently  to  cause  no 
little  discomfort  to  the  child,  and  oftentimes  the  lessening  of  the 
flow  for  a  day  or  two.  The  influence  of  the  mother's  mental  state 
upon  the  character  of  the  milk  was  early  brought  to  my  attention  while 
I  was  resident  physician  at  the  County  Branch  of  the  New  York 
Infant  Asylum.  In  this  institution  there  were  usually  about  two  hun- 
dred nursing  mothers,  the  majority  of  them  from  the  lower  walks  of 
life,  at  least  95  per  cent,  of  the  infants  being  illegitimate.  The  neces- 
sity of  placing  a  considerable  number  of  these  mothers  in  wards,  in 
close  social  contact,  gave  rise  to  rather  frequent  disputes,  and  not 
infrequently  to  fistic  encounters  of  a  decidedly  vigorous  character. 
After  a  particularly  active  disturbance,  several  nursing  infants  in  the 


HUMAN   MILK 


31 


ward  would  become  suddenly  ill,  usually  with  vomiting,  diarrhea,  and 
fever.  We  soon  learned  to  know  the  cause  when  inquiry  or  hasty 
inspection  showed  that  the  mothers  of  those  who  were  ill  had  been 
particularly  active  in  the  dispute.  A  small  proportion  of  the  mothers 
were  from  the  better  walks  of  life.  Letters  of  forgiveness  or  reproach 
or  visits  of  a  like  nature  from  fathers,  mothers,  or  sisters,  have  brought 
many  a  sick  baby  to  my  attention  and  caused  me  many  anxious 
moments. 

Conditions  Which  Call  for  Temporary  Discontinuance  of  Nursing. — 
During  an  acute  illness  with  fever,  such  as  indigestion,  tonsillitis,  and 
minor  illnesses  of  a  like  nature,  nursing  should  be  discontinued  for  a  day 
or  two.  During  this  period  it  should  be  our  effort  to  maintain  the  flow 
of  the  milk.  This  is  best  done  by  emptying  the  breast  with  a  breast- 
pump  at  the  usual  nursing  period  until  the  time  arrives  when  the 
nursing  may  be  resumed.  In 
such  conditions  the  advantage 
of  having  the  baby  accustomed 
to  one  bottle  a  day  will  at  once 
be  appreciated. 

Care  of  the  Nipples.^ — Six 
hours  after  delivery  or  confine- 
ment the  nipples  should  be 
washed  with  a  saturated  solu- 
tion of  boric  acid  and  the  child 
put  to  the  breast  and  nursing 
attempted.  After  this,  the  at- 
tempts at  nursing  should  be  re- 
peated every  four  hours, 
although  the  milk  does  not 
appear  in  the  breasts  until  from 
forty-eight  to  seventy-two 
hours  after  the  birth  of  the 
child.  Colostrum  may  be  pres- 
ent. It  is  useful  as  a  laxative  and  may  satisfy  the  child.  A  further 
advantage  of  the  nursing  at  this  time  is  that  it  gradually  accustoms 
both  the  infant  and  the  nipple  to  what  will  be  required  later.  Imme- 
diately after  the  nursing  the  nipple  should  be  carefully  washed  with 
a  saturated  solution  of  boric  acid  and  thoroughly  but  gentl}^  dried. 
A  baby  should  never  be  allowed  to  nurse  from  a  cracked  or  fissured 
nipple.  For  this  very  painful  condition  a  nipple-shield  (Fig.  1)  should 
always  be  used. 

HUMAN  MILK 

While  human  milk  varies  as  to  the  proportion  of  its  nutritional 
elements  at  different  periods  of  lactation,  and  even  at  different  times  of 
the  day,  milks  upon  which  infants  thrive  agree  within  certain  limits, 
so  that  a  standard  of  limitations  may  be  laid  down.  Among  a  great 
many  specimens  which  I  have  examined  the  solids  have  ranged  between 


Fig.  1. — Nipple-shield. 


32  THE    PRACTICE    OF    PEDIATRICS 

12  and  13  per  cent.  The  range  in  fat  has  been  from  2.75  to  4.65  per 
cent.,  proteid  from  0.9  to  1.8  per  cent.,  sugar  from  5.50  to  7.3  per  cent. 
These  figures  represent  the  analyses  of  the  breast-milks  given  children 
who  were  thriving  and  who  were  of  different  ages.  The  variations 
are  not  as  wide  as  have  been  reported  by  others,  but  it  is  to  be  remem- 
bered that  all  these  babies  were  thriving.  Whoever  has  examined 
breast-milk  even  a  few  times  is  aware  of  the  existence  of  the  widest 
possible  variations.  I  have  seen  breast-milks  which  contained  8  per 
cent,  of  fat  and  others  which  contained  only  0.5  per  cent.;  but  chil- 
dren thus  fed  were  not  well.  Fat  exists  in  mother's  milk  as  minute 
globules  in  emulsion,  varying  somewhat  in  composition,  depending 
upon  the  kind  of  food  eaten. 

The  proteids  of  breast-milk  offer  a  wide  field  for  further  study. 
There  are  several  of  these  proteids,  the  most  important  being  casein 
and  lactalbumin.  The  proportions  are  subject  to  considerable  varia- 
tion, depending  upon  the  diet  and  habits  of  life  of  the  producer.  With 
a  continuation  of  lactation  there  is  a  diminution  of  the  proteid,  so  that 
at  the  ninth  or  tenth  month  it  is  considerably  reduced,  the  total 
proteid  often  being  not  over  1  per  cent.  The  sugar  content  varies 
less  than  does  either  the  fat  or  proteid,  its  range  of  limitation,  even 
in  milk  otherwise  poor,  being  not  over  1.5  or  2  per  cent. 

Directions  for  nursing  well  children  will  be  found  on  page  26. 

Whether  or  not  the  child  is  getting  a  sufficient  quantity,  of  milk  may 
be  determined  by  weighing  the  baby  before  and  after  nursing.  For  this 
purpose  the  scales  used  for  weighing  children  should  weigh  accurately 
in  one-half  ounces.  The  child,  who  need  not  be  undressed,  should  be 
weighed  when  put  to  the  breast  and  weighed  at  the  completion  of  the 
nursing.  I  have  repeatedly  found  that  children  who  should  get  three 
ounces  or  more  at  a  feeding,  during  the  fifteen-minute  nursings  had  in- 
creased in  weight  but  one-half  or  one  ounce,  showing  that  only  so 
much  milk  had  been  taken.  Occasionally  cases  have  been  seen  where 
there  was  no  gain  whatever  after  nursing  and  yet  the  child  was  sup- 
posed to  have  been  fed.  In  the  event  of  difficult  breast-feeding  it  is 
well  for  the  physician  personally  to  supervise  a  nursing  or  two,  for  by 
this  means  much  valuable  information  may  be  gained. 

Examination  of  Human  Milk. — Milk  of  the  mother  is  usually  ex- 
amined to  determine  whether  it  contains  a  sufficient  amount  of  fat, 
sugar,  and  proteid  to  nourish  the  infant;  or  to  determine  whether  the 
quantity  of  one  or  more  of  the  nutritional  factors  is  excessive  or  deficient. 
Microscopic  examination  shows  us  little  except  the  presence  of  colostrum, 
which  usually  disappears  about  the  ninth  day  and  is  to  be  considered 
abnormal  if  present  after  the  twelfth  day.  The  presence  of  blood  and 
pus  may  also  be  detected  by  the  microscope.  For  an  accurate  analysis 
the  milk  should  be  sent  to  a  laboratory  properly  equipped  for  such  work. 
For  absolute  accuracy  it  is  not  safe  to  judge  from  the  analysis  of  one 
specimen  of  milk;  at  least  two,  better  three,  specimens  should  be 
analyzed  before  coming  to  a  conclusion.  In  collecting  milk  for  exami- 
nation the  middle  of  a  nursing  should  be  selected. 


THE    WET-NURSE  33 


THE  WET-NURSE 


We  are  called  upon  to  select  a  wet-nurse  under  various  conditions. 
A  few  families,  particularly  those  who  have  had  disastrous  feeding  ex- 
periences, ask  that  no  attempts  at  artificial  feeding  be  made,  but  that 
a  wet-nurse  be  engaged  in  advance  of  the  confinement  so  as  to  be 
ready  when  the  time  for  her  service  arrives.  Usually,  however,  our 
minds  and  those  of  the  parents  turn  to  the  wet-nurse  when  nutrition 
by  other  means  is  a  failure.  It  is  well  to  remember  in  this  connection 
that  it  is  not  wise  to  postpone  our  resort  to  the  wet-nurse  until  every 
chance  for  her  being  of  assistance  has  passed.  I  may  take  a  few 
days'  observation  or  but  a  single  glance  at  one  of  these  difficult 
feeding  cases  to  decide  whether  a  wet-nurse  must  be  secured.  Cer- 
tain it  is  that  in  a  few  cases  v/e  cannot  do  without  such  aid.  I  see  per- 
haps two  or  three  cases  a  year,  usually  in  consultation,  in  which  I  insist 
that  further  attempts  at  artificial  feeding  be  discontinued  because  of 
the  reduced  condition  of  the  patient. 

In  the  selection  of  a  wet-nurse  the  age  during  which  nursing  is 
most  successfully  carried  on  is  to  be  remembered.  As  a  rule,  a  wet- 
nurse  should  not  be  under  twenty-two  or  over  thirty-five  years  of  age. 
The  peasant  women  of  the  continent  of  Europe  make  the  best  wet- 
nurses.  A  woman  should  not  be  selected  as  a  wet-nurse  without  a 
thorough  examination  both  of  herself  and  of  her  infant,  including  the 
Wassermann  test  for  syphilis.  She  must  be  free  from  skin  diseases, 
tuberculosis,  and  syphilis.  Whether  she  is  stout  or  thin,  tall  or  short, 
amounts  to  little.  Neither  can  we  place  much  reliance  on  the  size  of 
her  breasts.  Although  full,  firm  breasts  and  prominent  nipples  are 
desirable,  the  best  indication  as  to  her  nursing  ability  is  the  condition 
of  her  baby.  For  this  reason  it  is  best  not  to  select  a  woman  before 
her  baby  is  four  weeks  old,  for  by  that  time  his  physical  condition  will 
indicate  with  considerable  accuracy  the  kind  of  food  he  has  been 
getting.  The  wet-nurse's  milk  need  not  correspond  with  the  age  of 
the  patient  for  whom  she  is  engaged,  as  breast-milk  from  the  fourth 
week  to  the  third    month  of  lactation  will  answer  for  any  infant. 

The  results  attending  the  first  few  days  of  wet-nursing  are  often 
most  disappointing.  The  radical  change  which  takes  place  in  the 
nurse's  habits  of  life,  necessitating  the  leaving  of  her  own  child  to  the 
care  of  others,  sometimes  produces  nervous  conditions  which  may  have 
a  decidedly  unfavorable  influence  upon  her  milk.  Before  arriving  at 
the  conclusion  that  she  will  not  answer  in  a  given  case,  she  should  there- 
fore have  time  to  adjust  herself  to  the  changed  conditions.  Many  a 
good  wet-nurse,  accustomed  to  a  very  plain  diet  and  some  work,  which 
necessarily  means  exercise,  has  been  ruined,  so  far  as  her  usefulness  as 
a  milk-producer  is  concerned,  by  overindulgence  at  the  table.  Upon 
assuming  her  new  office  she  is  temporarily  the  most  important  member 
of  the  household,  next  to  the  baby,  and  articles  of  food  are  supplied  to 
which  she  is  entirely  unaccustomed  and  of  which  she  eats  plentifull5^ 
The  result  is  an  attack  of  indigestion  with  fever,  the  baby  is  made  ill, 
3 


34  THE    PRACTICE    OF    PEDIATRICS 

and  the  usefulness  of  the  wet-nurse  in  the  family  ceases.  These  women 
usually  do  best  upon  a  plain  diet  of  meat,  poultry,  fish,  vegetables, 
cereals,  and  milk.  If  they  are  accustomed  to  taking  beer,  one  bottle 
daily  may  be  permitted.  Coffee  may  be  allowed  to  the  extent  of  one  cup 
daily,  and  of  tea  not  more  than  two  cups  should  be  allowed.  Women 
of  this  class  are  almost  invariably  neglectful  of  the  bowel  function,  so 
that  this  must  be  attended  to.  One  free  evacuation  should  take  place 
daily.  As  a  rule,  the  wet-nurse  has  been  accustomed  to  work  and 
will  be  more  contented  and  happy  when  her  time  is  occupied.  If  she 
possess  sufficient  intelligence  to  take  the  baby  for  outings,  she  should 
be  allowed  to  do  so.  Being  out-of-doors  from  three  to  four  hours  a 
day  is  of  decided  advantage  to  every  nursing  woman.  For  the  com- 
fort of  the  family  it  is  wise  not  to  let  a  wet-nurse  know  her  full  value. 
When  she  feels  that  she  is  indispensable,  trouble  is  apt  to  follow. 
It  is  particularly  necessary,  therefore,  that  babies  who  are  wet-nursed 
should  be  given  one  bottle-feeding  daily  as  soon  as  they  are  able  to 
take  care  of  it.  The  wet-nurse  will  then  realize  that  she  can  be  dis- 
pensed with  in  case  of  misconduct,  or  if  she  leave  with  an  hour's 
notice  the  child  can  be  given  the  bottle  until  another  nurse  is  secured. 
In  the  great  majority  of  my  cases  it  has  not  been  necessary  to  continue 
the  wet-nursing  after  the  children  are  seven  months  of  age,  for  by  this 
time  they  can  usually  be  fed  on  the  bottle.  Of  course,  unless  her 
nursing  proves  unsatisfactory,  a  wet-nurse  should  not  be  dismissed 
at  the  commencement  of  or  during  the  summer. 

THE  BREAST 

Cracked  and  Fissured  Nipples. — Fissures  of  the  nipples  often  re- 
sult from  lack  of  care  and  cleanliness.  Nipples  that  are  not  washed  and 
dried,  but  allowed  to  remain  moist  after  nursing,  particularly  during 
the  first  few  days,  are  also  very  apt  to  become  macerated  and  cracked. 
In  the  cases  in  which  there  is  a  tendency  for  the  breasts  to  "leak, "  the 
milk  decomposes  on  the  nipples,  and  the  nipple  becomes  actually  ex- 
coriated by  the  acids  formed  by  the  decomposition  in  the  milk.  Leak- 
ing nipples  should  be  kept  covered  with  pads  of  sterile  absorbent  gauze. 
Cracks  and  fissures  in  the  nipple  may  be  sufficiently  painful  to  pre- 
vent a  continuance  of  the  nursing.  In  getting  the  histories  of  not  a 
few  bottle  babies,  I  have  been  told  that  nursing  had  been  stopped  be- 
cause of  cracked  nipples.  The  prevention  and  successful  treatment 
of  the  condition,  therefore,  is  a  matter  of  no  little  importance.  A 
strong  child  tugging  on  a  fissured  nipple  may  occasion  excruciating 
pain  to  the  mother,  and  when  the  fissures  are  not  healed,  it  can  readily 
be  understood  that  such  pain  and  the  dread  of  nursing  may  produce 
sufficient  mental  distress  to  change  the  character  or  stop  the  flow  of 
the  milk,  either  of  which  conditions  may  require  that  the  nursing  be 
discontinued. 

Treatment. — The  treatment  which  gives  the  best  results,  and  which 
is  used  at  the  New  York  Nursery  and  Child's  Hospital,  is  to  bathe 
the  parts  with  a  saturated  solution  of  boric  acid  after  each  nursing, 


THE    BREAST  35 

dry  the  nipple,  and  apply  a  pad  of  sterile  gauze.  Once  or  twice  a  day 
the  cracks  or  fissures  are  painted  with  an  8  per  cent,  solution  of  silver 
nitrate.  There  is  no  pain  attending  this  application.  The  pad  of 
sterile  gauze  just  referred  to  is  placed  over  the  nipple  and  held  in  posi- 
tion by  a  binder  sufficiently  tight  to  support  the  breasts.  Before  the 
nursing  the  nipple  is  bathed  with  sterile  water  and  the  infant  takes 
the  breast  as  usual.  If  there  are  deep  fissures,  it  may  be  well  for  a  day 
or  two  to  use  a  nipple-shield  (Fig.  1).  Another  important  reason 
for  a  rapid  healing  is  the  danger  of  infecting  the  gland  through  the  open 
nipple  wound — the  usual  cause  of  mammary  abscess.  The  use  of  an 
ointm_ent  on  the  nipples  is  not  advised,  for  the  reason  that  it  is  of  little 
or  no  service,  and  in  most  cases  ointments  do  actual  harm  because  they 
soften  the  epithelium  and  make  the  nipple  tender.  Diminishing  the 
number  of  nursings  to  three  daily  has  been  of  use  in  some  severe  cases 
which  were  slow  to  response  of  treatment.  Removing  the  child  from 
the  breast  entirely  is  to  be  advised  only  under  conditions  of  much  ur- 
gency. The  milk  may  be  entirely  lost  as  a  result  of  protracted  ab- 
sence of  this  stimulation  to  the  breast. 


Pig.  2. — English  breast-pump. 

Depressed  Nipples.^ — Not  an  infrequent  source  of  difiiculty  in  the 
management  of  the  nursing  function  in  a  primipara  is  depressed  nipples. 
The  child  cannot  get  a  sufficient  hold  to  make  suction  possible.  He 
thus  fails  to  get  the  desired  nutriment,  and  in  consequence  both  the 
child  and  the  mother  become  exhausted.  When  this  is  repeated  a  few 
times,  the  child  is  very  apt  to  refuse  to  make  any  attempt  at  nursing. 
In  such  cases  the  use  of  the  nipple-shield  is  often  indispensable,  until 
the  nipple  is  sufficiently  drawn  out  and  developed  for  the  child  to  get 
hold  of.  Preceding  each  nursing  it  is  well  to  manipulate  the  nipple 
for  a  few  minutes  or  to  elongate  it  by  the  use  of  the  breast-pump 
(Fig.  2),  without  using  sufficient  force  to  draw  the  milk. 

Caking  of  the  Breasts. — So-called  caking  of  the  breasts  is  of  very 
frequent  occurrence  during  the  first  few  days  of  nursing.  The  milk, 
when  it  appears  in  the  breasts,  is  often  secreted  in  large  amount.  A 
great  deal  more  is  supplied  than  the  child,  with  his  small  stomach  and 
usually  indifferent  nursing,  is  able  to  digest.  The  breasts  should  be 
watched  very  carefully  during  this  time  so  as  to  guard  against  the 


36  THE    PRACTICE    OF    PEDIATRICS 

possibility  of  the  milk  remaining  undrawn.  After  the  completion  of 
the  regular  nursing,  if  a  considerable  amount  of  milk  remains  in  the 
breasts,  it  should  be  drawn  by  the  breast-pump  (Fig.  2)  and  the  breast 
thus  relieved. 

Caking  is  frequently  the  outcome  of  fissured  nipples.  Sucking  on 
the  part  of  the  child,  the  use  of  the  breast-pump,  and  hard  pressure  in 
milking  are  all-  very  painful  procedures,  with  the  result  that  the  milk 
remains  undrawn. 

Treatment. — When  nodules  form,  they  may  readily  be  softened  by 
gentle  massage.  Lanolin  should  be  used  on  the  fingers  so  as  to  avoid 
unnecessary  irritation  of  the  skin.  The  massage  should  be  repeated  as 
often  as  the  nodules  appear.  The  caking  is  more  apt  to  occur  in  the 
dependent  portion  of  the  glands.  The  so-called  pendulous  breasts, 
which  may  show  a  tendency  to  cake,  should  be  supported  by  a  binder 
lightly  applied. 

Acute  and  Suppurative  Mastitis.' — When  inflammation  of  the 
breast  develops  with  fever,  chills,  and  prostration,  it  is  usually  the  re- 
sult of  an  infection  through  the  nipple,  generally  one  with  visible 
cracks  and  fissures.  For  our  purposes  the  different  varieties  of 
mastitis  need  not  be  considered.  Nursing  from  the  involved  breast 
should  be  discontinued,  for  the  sake  of  both  the  child  and  the 
mother;  in  fact,  the  pain  is  often  so  great  that  nursing  is  impossible. 
A  supporting  bandage  should  be  applied  and  the  milk  drawn 
with  the  breast-pump  at  the  usual  nursing  times.  It  must  be 
our  aim  to  induce  resolution  without  the  formation  of  pus.  This 
is  best  accomplished  by  the  use  of  an  ice-bag  which  is  applied 
to  the  inflamed,  indurated  area.  If  there  is  a  tendency  to 
constipation,  saline  laxatives  should  be  used.  In  fact,  the  patient  will 
often  be  beneflted  not  a  little  by  two  or  three  watery  evacuations  daily. 
With  a  subsidence  of  the  temperature  and  an  abatement  of  the  inflam- 
mation, nursing  may  be  resumed.  As  soon  as  the  presence  of  pus  is 
determined,  it  should  be  removed  regardless  of  its  location  in  the  gland. 
I  have  seen  cases  of  intestinal  infection  in  the  infant  and  of  infectious 
processes  in  other  parts  of  the  body,  that  were  undoubtedly  due  to 
nursing  from  suppurating  breasts. 

THE  NURSERY 

The  nursery  should  be  the  largest  and  best  ventilated  room  in  the 
house.  In  a  city  home  the  room  may  well  be  located  on  the  third  or 
fourth  floor,  with  a  southern  exposure.  In  apartments,  quiet  and  the 
possibility  of  free  ventilation  and  sunlight  must  be  considered  in 
selecting  the  room.  For  the  sake  of  quiet,  the  nursery  should  not 
communicate  with  the  sleeping-rooms  of  older  children. 

In  placing  children  in  sleeping-rooms  or  in  a  nursery ,  or  in  estimating 
the  capacity  of  hospital  wards  for  children,  it  is  to  be  remembered  that 
at  least  one  thousand  cubic  feet  of  air-space  should  be  allowed  to  each 
child. 

The  floor  of  the  nursery  should  not  be  carpeted.     A  hard-wood 


THE    NURSERY  37 

floor  is  best.  If  this  is  not  possible,  covering  the  floor  with  oil-cloth 
or  linoleum  is  always  possible.  This  can  be  cleaned  with  a  damp  cloth 
every  day.  A  broom  should  never  be  used  in  a  nursery.  Paint  or 
hard  finish  on  the  walls  is  preferable  to  paper.  There  should  be  at 
least  two  windows  and  an  open  fireplace.  If  possible,  the  bath-room 
should  be  connected  with  the  nursery,  to  be  used  not  only  for  bathing 
the  child  but  as  a  "changing  room."  The  child's  napkins  should  not  be 
changed  in  its  living-room  if  it  can  be  avoided.  It  is  needless  to  say 
that  napkins  should  never  be  dried  in  the  nursery. 

Steam  heat  as  ordinarily  used  today  is  the  least  desirable  means 
of  heating,  on  account  of  its  uncertainty.  In  many  New  York  apart- 
ments of  the  better  class,  the  fires  are  banked  at  10  p.  m.  ;  the  tempera- 
ture when  the  child  retires  is  perhaps  70°;  by  five  or  six  o'clock  in 
the  morning  a  fall  to  50°  or  60°F.  has  taken  place.  Such  a  change 
in  the  temperature,  with  the  tendency  of  children  to  kick  off  the 
bed-clothes,  explains  many  cases  of  tonsillitis  and  bronchitis.  The 
temperature  of  the  nursery  should  be  kept  as  even  as  possible.  When 
for  any  reason  this  cannot  be  controlled,  it  is  best  to  have  two  means  of 
heating,  so  that  when  one  fails  the  other  may  be  used.  The  open  grate 
fire  or  a  small  wood-stove  is  best.  Gas  should  never  be  employed  as 
a  means  of  heating  a  child's  sleeping-room,  on  account  of  the  rapid 
exhaustion  of  the  oxygen  which  results  from  its  use. 

The  furniture  of  the  nursery  should  be  of  the  plainest.  Hard- wood 
chairs  and  tables  with  enamel  or  brass  cribs  or  bedsteads  should  be 
used.  There  should  be  no  arti  cle  of  furniture  or  furnishings  in  a  nursery, 
that  cannot  be  washed.  In  the  bath-room  or  in  some  room  adjoining 
a  pail  should  be  kept  containing  some  disinfectant  solution,  such  as 
carbolic  acid,  1  :  100,  or  carbonate  of  soda  solution,  1  ounce  to  2  gallons 
of  water,  in  which  the  napkins  are  placed  as  soon  as  soiled. 

There  should  be  two  shades  at  each  window,  a  light  and  a  dark  one, 
so  that  it  will  be  possible  to  darken  the  room  during  the  sleeping  time, 
as  well  as  to  exclude  the  early  morning  light,  which  is  the  usual  cause 
of  too  early  waking.  Babies  should  be  taught  to  sleep  until  at  least  6 
o  'clock  in  the  morning.  This  is  far  better  for  the  child  and  also  for  the 
mother  if  she  occupies  the  same  room.  The  unnecessary  habit  of  an 
early  waking  at  4  or  5  o'clock  will  in  most  instances  readily  be  broken 
by  keeping  the  room  dark. 

The  nursery  should  have  suitable  means  for  ventilation.  For  this 
purpose,  aside  from  the  fireplace,  I  have  found  the  window-board 
of  no  little  service.  It  can  be  made  of  any  width.  Ordinarily,  I  have 
it  made  about  six  inches  wide.  It  is  sawed  so  as  to  fit  tightly  under 
the  lower  sash.  This  leaves  an  open  space  corresponding  to  the  width 
of  the  board  between  the  upper  and  lower  sash,  and  allows  the  en- 
trance of  a  current  of  air  which  is  directed  upward.  There  should  be  a 
thermometer  in  every  child's  living-room  or  nursery.  It  should  reg- 
ister from  70°  to  72°F.  by  day  and  from  60°  to  65°F.  by  night.  The 
nursery  should  be  given  an  hour's  airing  twice  a  day.  The  child 
should  sleep  in  a  crib,  alone,  not  with  an  adult  or  an  older  child. 


38  THE    PRACTICE    OF    PEDIATRICS 

The  old-fashioned  cradle  in  which  generations  have  been  rocked  may  be 
an  interesting  heirloom,  but  under  no  circumstances  should  it  be  re- 
moved from  its  place  in  the  garret.  It  is  realized  that  the  above  sug- 
gestions are  not  applicable  in  many  homes.  Nevertheless,  if  we  aim  at 
the  ideal,  existing  conditions,  no  matter  how  unpromising,  will  in- 
variably be  made  better. 

THE  NURSERY  MAID 

In  certain  stations  and  conditions  of  society  the  young  child  is 
cared  for  by  the  mother  with  the  assistance  of  the  immediate  members 
of  the  family.  In  thousands  of  homes,  however,  a  helper  is  employed 
to  take  charge  of  the  child  or  assist  in  its  care.  The  selection  of  a 
nursery  maid  is  a  matter  of  much  importance.  Schools  for  training 
nursery  maids  exist  in  New  York  City,  Boston,  Albany,  Newark  (New 
Jersey),  and  doubtless  in  other  cities.  Although  such  trained  help  is 
greatly  to  be  desired,  the  supply  is  very  limited.  Some  of  my  best 
children's  attendants  have  been  women  who,  although  they  have  not 
passed  the  meridian  of  life,  still  have  reached  the  seasoned  age  when 
the  attractive  qualities  of  policemen  and  grocery  boys  have  faded  into 
a  dim  recollection.  Any  industrious,  sensible  young  woman  of  quiet 
tastes  who  is  fond  of  children  can  be  trained  in  a  few  weeks  into  a  most 
useful  helper.  The  association  of  the  nursery  maid  and  child  is  a  close 
one,  and  it  is  the  physician's  duty  to  know  that  the  applicant  is  phys- 
ically fit  for  the  position. 

During  a  single  year  the  writer  has  known  of  three  nursery  maids  who 
developed  pulmonary  tuberculosis  while  in  service.  Not  only  should 
the  applicant's  lungs  be  examined,  but  also  the  mouth,  nose,  and  throat. 
Carious  teeth  and  diseased  conditions  of  the  throat  and  nose  should 
receive  careful  attention  before  the  maid  is  allowed  to  assume  the 
position.  It  is  also  important  that  something  of  the  applicant's  pre- 
vious life  should  be  known. 

One  of  the  most  important  things  to  know  about  an  applicant  in  a 
large  city,  and  one  most  difficult  for  the  physician  to  discover,  is  the 
existence  of  leukorrhea,  or  vaginal  discharge.*  This,  however,  can 
usually  be  discovered  by  the  tactful  young  mother.  Not  only  should 
the  ideal  nursery  maid  be  physically  fit,  she  must  be  mentally  fit  as  well. 
For  proper  mental  and  physical  development,  children  must  be  enter- 
tained and  pleasantly  employed.  An  ill-natured,  impatient  nurse 
should  be  forced  to  seek  other  employment.  It  should  not  be  a  task 
for  a  child's  attendant  to  play  with  him.  A  woman  should  not  be  con- 
demned, however,  because  she  fails  with  any  given  child.  With  a  child 
differently  situated,  with  a  different  temperament,  the  results  may  be 
perfectly  satisfactory. 

WEIGHT 

The  average  weight  of  the  full-term,  newly  born  infant  varies  from 
six  to  nine  pounds.     Some  are  born  at  term  weighing  less  than  six 

*  A  very  severe  gonorrhea  was  contracted  by  one  of  my  patients  from  a  nursery 
maid. 


WEIGHT  39 

pounds  and  a  few  weighing  over  nine  pounds,  but  in  the  great  majorit}' 
the  birth-weight  will  be  found  between  these  figures.  Holt  found  from 
a  study  of  the  records  of  three  large  maternity  institutions  in  New 
York  City  as  follows: 

The  average  weight  of  568  females  was  7.16  pounds. 

The  average  weight  of  590  males  was  7.55  pounds. 

Every  family  which  can  afford  it  should  have  a  scale  (p.  41)  for 
weighing  the  baby,  for  only  by  regular  weighing  during  infancy  and 
childhood  can  we  gain  an  accurate  knowledge  of  growth.  During  the 
first  five  days  of  life  there  is  usually  a  loss  in  weight  of  four  to  six  ounces. 
After  this  initial  loss,  which  may  be  expected  but  which  does  not  always 
occur,  a  weekly  gain  in  weight  is  to  be  looked  for,  the  child  regaining 
the  birth-weight  on  the  eighth  or  tenth  day.  At  first  it  is  advisable  to 
weigh  twice  a  week,  or  even  daily,  if  the  child  is  not  progressing  satis- 
factorily. After  the  second  month,  when  the  infant  is  making  satis- 
factory progress,  a  weekly  weighing  will  answer,  and  this  should  be 
continued  until  the  child  is  one  year  of  age.  Dwring  the  second  year, 
bi-monthly  weighings  are  sufficient.  Girls  of  the  same  age,  after  the 
first  year,  will  average  from  one-half  to  one  pound  lighter  than  boys. 
During  the  third  year,  monthly  weighings  will  be  sufficient  to  enable 
one  to  keep  in  touch  with  the  child's  condition.  During  the  first  six 
months  of  life  a  weekly  gain  of  four  to  eight  ounces  has  been  made  by 
the  well  children  under  my  care.  When  a  child  does  not  make  at  least 
an  average  gain  of  four  ounces  weekly,  I  do  not  put  him  in  the  "doing 
well"  class,  but  look  into  his  care  and  nutrition  to  learn  what  is  wrong. 
Children  vary  in  growing  capacity.  Some  will  increase  in  weight  rap- 
idly, gaining  three  ounces  a  day,  while  others  will  make  a  slower  gain 
and  yet  be  perfectly  well.  Through  the  care  of  many  children,  I  have 
come  to  regard  four  ounces  as  the  minimum  weekly  gain  for  a  well  child. 
In  a  well  infant  the  birth-weight  should  be  doubled  by  the  fifth  or  the 
sixth  month,  and  at  one  year  the  weight  should  be  a  little  over  two  and 
one-half  times  that  at  birth.  During  the  second  year  a  gain  of  five 
and  one-half  to  seven  pounds  will  usually  result  under  proper  condi- 
tions. During  the  third  year  from  five  to  six  pounds  will  be  added. 
At  the  fifth  year  the  weight  should  be  in  the  neighborhood  of  forty-one 
pounds.  It  is  not  to  be  inferred  that  these  are  arbitrary  figures  or  that 
perfectly  well  children  may  not  be  under  or  above  the  figures  given  at 
the  ages  mentioned.  These  figures  are,  however,  to  be  regarded  as 
the  average  for  the  different  ages. 

A  weight  chart  with  its  colored  "normal"  line  will  not  be  found  in 
this  book,  and  physicians  are  advised  against  its  use.  Time  and  again  I 
have  seen  well  infants,  though  slow  in  growth,  made  ill  by  overfeeding, 
in  the  vain  attempts  of  an  ambitious  mother  or  nurse  to  keep  her  in- 
fant up  to  the  "normal"  line. 

The  weighing  alone  is  not  sufficient  to  inform  us  absolutely  con- 
cerning the  development  of  children.  I  have  seen  babies  who  showed 
a  most  satisfactory  weight  curve,  yet  who,  on  examination,  were  by  no 
means  up  to  the  requirements  for  their  age  as  regards  their  bone  and 


40 


THE    PRACTICE    OF    PEDIATRICS 


muscle  development.  A  nursing  or  bottle  baby  should  be  examined 
once  a  month  in  order  to  determine  if  the  progress  is  along  the  desired 
lines  as  shown  by  the  condition  of  the  teeth,  the  fontanels,  the  long 
bones,  and  the  muscles. 

The  following  table  from  Holt's  "Diseases  of  Infancy  and  Child- 
hood" gives  the  weight  and  height  of  children  from  birth  to  the  six- 
teenth year.  The  weights  under  five  years  are  taken  without  clothing. 
After  the  fifth  year  the  weight  of  the  clothing  is  to  be  deducted.  The 
average  weight  of  house-clothing,  according  to  Holt,  who  quotes  Bow- 
ditch,  is  at  the  fifth  year  2.8  pounds  for  both  sexes;  at  the  seventh  year, 
3.5  pounds  for  both  sexes;  at  the  tenth  year,  5.7  pounds  for  boys  and 
4.5  pounds  for  girls;  at  the  thirteenth  year,  7.4  pounds  for  boys  and  5.6 
pounds  for  girls;  at  the  sixteenth  year,  9.7  pounds  for  boys  and  8.1 
for  girls.  These  weights  must  be  deducted  from  the  gross  weights  in 
order  to  obtain  the  net  weights  of  the  children.  The  season  of  the  year, 
of  course,  would  make  some  difference  in  the  weight  of  the  clothing, 
although  this  point  is  not  mentioned  by  the  observers. 


Age. 


Birth. 


Sex. 


Weight, 
Pounds. 


/Boys 7.55 


6  months. 
12  months. 
18  months. 


\  Girls 
Boys 
Girls 
Boys 
Girls 
Boys 
Girls 


7.16 
16.0 
15.5 
21.0 
20.5 
24.0 
23.5 


"^  y^^^^ \  Girls 26.0 

/Boys 32.0 

1  Girls 31.0 

/Boys 36.0 

\  Girls 35.0 

/Boys 41.2 

1  Girls 39.8 

/Boys 45.1 

1  Girls ;.  ...43.8 

/Boys 49.5 

1  Girls 48.0 

/  Boys 54 . 5 


3  years. 

4  years. 

5  years. 

6  years. 

7  years. 

8  years. 

9  years. 

10  years. 

11  years. 

12  years. 

13  years. 

14  years. 

15  years. 

16  years. 


\  Girls 52.9 

Bovs 60.0 

Girls 57.5 

Boys 66.6 

Girls 64.1 

/Boys 72.4 

\  Girls 70.3 

Boys 79.8 

Girls 81.4 

Boys 88.3 

Girls 91.2 

/Boys 99.3 

\  Girls ; 100.3 

/Boys 110.8 

/Girls 108.4 

/Boys 123.7 

\  Girls 113.0 


Height, 
Inches. 

20.6 
20.5 
25.4 
25.0 
29.0 
28.7 
30.0 
29.7 
32.5 
32.5 
35.0 
35.0 
38.0 
38.0 
41.7 
41.4 
44.1 
43.6 
46.2 
45.9 
48.2 
48.0 
50.1 
49.6 
52.2 
51.8 
54.0 
53.8 
55.8 
57.1 
58.2 
58.7 
61.0 
60.3 
63.0 
61.4 
65.6 
61.7 


The  above  table  allows  of  considerable  latitude  and  with  the  child 


THE  CAKE  OF  THE  STUMP  OF  THE  UMBILICAL  CORD    41 

remaining  within  the  normal.     A  boy  patient  who  represented  most 
rapid  growth  measured  69%  inches  when  12  years  of  age. 

Scales.  —A  scale  for  weighing  the  baby  is  a  very  necessary  adjunct 
to  the  nursery  furnishings.  There  are  several  varieties  of  scales  on  the 
market  known  as  "baby  scales."  Their  usual  construction  provides 
for  a  basket  for  holding  the  baby,  the  basket  being  supported  by  a  steel 
rod  which  rests  upon  a  spring.  A  needle  indicates  on  a  dial  the  weight 
of  the  child.  This  variety  of  scale  is  very  unsatisfactory :  it  gets  out  of 
order  easily,  it  is  expensive,  and  with  a  vigorous,  kicking  child,  the  rapid 
oscillation  of  the  needle  makes  an  accurate  reading  of  the  weight  dif- 
ficult if  not  impossible.  Further,  the  weight  capacity  of  these  scales 
is  but  twenty  pounds.  When  the  child's  weight  reaches  this  figure, 
it  necessitates  the  purchase  of  another  scale.  The  scoop  and  platform 
scales  used  by  grocers  are  best.  They  do  not  easily  get  out  of  order, 
they  weigh  correctly  from  one-half  ounce  to  two  hundred  and  eighty 
pounds,  and  being  very  simple  in  construction,  they  can  readily  be 
understood.  The  infant  rests  on  his  back  in  the  scoop  during  the 
weighing  process;  older  children  stand  on  the  platform. 

HEIGHT 

The  length  or  height  of  children  at  the  various  ages  is  for  conven- 
ience included  in  the  weight  table.  From  the  standpoint  of  health  or 
development,  height  is  of  no  great  significance.  The  length  at  birth 
usually  varies  from  IQi-^  to  21  inches.  Children  suffering  from  tardy 
malnutrition,  particularly  if  syphilitic,  may  be  undersized.  Not  a  few 
of  the  non-specific  malnutrition  and  anemic  children  are  tall  and  thin. 
It  is  often  a  matter  of  no  little  distress  to  parents  that  their  children 
are  undersized.  Short  mothers  and  fathers  cannot  expect  very  tall 
children.  If  the  latter  have  right  care,  they  will  probably  be  larger 
than  the  parents,  but  cannot  be  expected  to  grow  as  much  as  play- 
mates whose  fathers  and  mothers  are  tall.  The  height  bears  much  less 
relation  to  the  condition  of  the  child  than  does  the  weight. 

THE  CARE  OF  THE  STUMP  OF  THE  UMBILICAL  CORD 

The  space  devoted  to  the  care  of  the  umbilical  cord  might  seem  out 
of  place  in  a  work  of  this  nature.  The  excuse  is  the  frequent  appear- 
ance in  private  practice  and  in  out-patient  clinics  of  infants  with 
umbilical  polypi,  granulomata,  suppurating  umbilical  stumps,  or 
eczema  involving  a  considerable  area  about  a  moist,  actively  secreting 
umbilicus.  The  management  of  granuloma,  polypus,  and  localized 
eczema  about  the  umbilicus  has  been  referred  to  elsewhere.  In  order 
to  secure  a  rapid  and  complete  cicatrization  after  the  cord  falls,  it  is 
essential  that  the  parts  be  kept  dry.  I  have  used  with  gratifying 
success  a  powder  composed  as  follows: 

I^     Pulveris  acidi  salicylic gr.  x 

Pulveris  acidi  borici gr.  xxv 

Pulveris  aniyli 

Pulveris  zinci  oxidi aa5ss 


42  THE    PRACTICE    OF    PEDIATRICS 

Over  this  powder,  which  is  used  freely  in  the  open  wound,  is  placed 
a  retaining  pad  of  gauze.  The  dressing  should  be  changed  and  fresh 
powder  applied  every  time  the  child  is  fed.  For  the  small  unhealthy 
granulations  often  present,  cauterizing  with  a  50  per  cent,  nitrate  of 
sUver  solution  may  be  necessary  once  or  twice,  after  which  the  powder 
should  be  used  until  the  secretion  has  entirely  ceased  and  cicatrization 
is  complete.    . 

MENTAL  AND  PHYSICAL  DEVELOPMENT  IN  THE  INFANT 

Dr.  Frederick  Peterson,*  of  New  York,  has  made  an  exhaustive 
study  of  the  mental  development  of  the  newly  born. 

In  all,  1060  newly  born  infants  were  examined,  the  observations 
extending  over  one  year.  His  observations,  which  are  to  be  looked  upon 
as  authentic,  are  as  follows: 

"1.  Sight. — Sensibility  to  light  is  present  in  most  infants  at  birth, 
and  this  is  the  case  even  in  those  prematurely  born.  The  optic  nerve 
is,  therefore,  already  prepared  to  receive  impressions,  sometimes  even 
before  the  time  of  normal  birth. 

''2.  Hearing.— Sensibility  to  sound  is  quite  as  apparent  as  sensi- 
bility to  light  at  birth,  for  276  normal  white  children  reacted  to  sound 
on  the  first  day  of  life,  and  146  reacted  to  light.  A  similar  condition 
existed  among  the  premature  infants,  many  reacting  to  sound  on  the 
first  day  as  well  as  to  light.  The  auditory  nerve  is  already  prepared  to 
receive  impressions  of  sound  sometimes  before  the  period  of  normal 
birth.     This  is  wholly  contrary  to  the  opinions  of  other  authorities. 

"  3.  Taste. — The  gustatory  nerve  not  only  reacts  differently  to  salt, 
sweet,  bitter,  and  sour  at  birth,  but  the  same  mimetic  reactions  are 
observed  in  premature  infants.  This  nerve  is,  therefore,  ready  to  re- 
ceive taste  impressions  some  time  before  the  normal  period  of  birth. 

"4.  Smell. — Two  hundred  and  seven  normal  white  children  reacted 
to  odors  on  the  first  day  of  birth,  and  similar  reactions  were  observed 
in  premature  infants.  The  olfactory  nerve  is  ready  to  receive  smell 
impressions  some  time  before  the  end  of  the  normal  period  of  gestation. 

"5.  Cutaneous  Sensibility. — Reactions  to  touch  and  temperature 
and  affective  manifestations  of  discomfort,  obtained  the  first  day  in 
large  numbers  of  normal  infants,  were  similarly  obtained  in  premature 
infants,  showing  that  such  sensibility  is  already  present  before  the  ex- 
piration of  the  period  of  normal  gestation.  There  is  every  reason  to 
believe  that  sensitiveness  to  painful  stimuli  is  present,  but  the  reactions 
are  more  vague  and  uncertain  than  in  later  life,  which  leads  many  to 
assume  that  the  sense  of  pain  is  dull  in  the  new-born.  Muscular  sense 
cannot  be  tested  in  infants,  but  there  is  every  reason  to  believe  that 
muscular  sense,  the  sense  of  motion,  and  sense  of  position  are  developed 
early  in  utero. 

"6.  Thirst-hunger  and  Organic  Sensation. — The  new-born  child 
frequently  reacts  to  thirst-hunger  on  the  first  day,  though  the  actual 
*  Bulletin,  Lying-in  Hospital,  December,  1910. 


MENTAL  AND    PHYSICAL   DEVELOPMENT   IN   THE    INFANT       43 

need  of  food  is  seldom  apparent  until  after  the  first  or  second  day. 
Discomfort  is  clearly  marked  when  nourishment  is  not  forthcoming. 
The  cries  of  discomfort  and  pain  are  marked  in  the  first  day  in  full- 
term  infants  and  noteworthy  in  the  premature. 

"7.  The  Beginning  of  Memory,  Feeling  and  Consciousness  in 
the  New-born  Child. — There  are  good  grounds  for  believing  that  the 
new-born  child  comes  to  the  world  already  with  a  small  store  of  experi- 
ences and  associated  feelings  and  shadowy  consciousness.  The  fact 
that  even  in  premature  infants  we  find  the  senses  already  prepared  for 
the  reception  of  impressions  on  the  five  senses  is  some  evidence  of  such 
impressions  having  been  already  received  and  stored  up  in  the  dim 
storehouse  of  a  memory  already  begun.  It  may  even  be  that  some  sort 
of  vague  light  impressions  have  been  received,  for  it  is  possible  that  in 
the  interior  of  the  body  the  alternation  of  day  and  night  may  in  a  mild 
degree  be  manifested.  The  transillumination  of  the  hands  before  a 
candle,  of  the  skull  and  face  bones  by  examination  of  the  frontal  sinuses 
and  antrum  with  electric  lights,  are  evidence  of  a  certain  amount  of 
translucency  of  the  whole  organism  to  sunlight,  which  is  so  much  more 
powerful  than  any  artificial  light.  There  is  greater  possibility  in  the 
matter  of  the  auditory  sense,  that  it  may  be  stimulated  by  sounds 
within  the  body  of  the  mother  (by  bone  conduction  possibly) ^ — such 
sounds  as  the  beats  of  the  maternal  and  fetal  hearts,  the  uterine  and 
funic  souffles,  and  the  bruit  of  the  maternal  aorta. 

"Moderate  stimulation  of  the  gustatory  nerve  is  thought  to  occur 
through  the  common  swallowing  of  amniotic  fluid  by  the  fetus. 

"  A  marked  development  of  receptivity  in  the  senses  of  touch  and  of 
muscular  sense  during  uterine  life  is  undisputed.  Movements  begin 
considerably  before  the  sixteenth  week  of  pregnancy,  and  increase  in 
character  and  extent  from  that  time  on.  Often  they  are  so  violent  as 
to  be  painful  to  the  mother.  The  activity  of  the  muscles  and  constant 
contact  of  various  parts  of  the  fetal  body  with  the  uterine  walls  for  a 
period  of  months  before  birth  must  lay  a  foundation  under  the  threshold 
of  consciousness  for  a  sense  of  equilibrium  and  vague  spatial  relations. 
The  material  basis  of  consciousness  is  prepared  long  before  birth. 

''There  is  already  a  feeling  tone  associated  with  the  earliest  re- 
actions, though  we  are  altogether  in  the  dark  as  regards  its  psychophys- 
iology.  The  process  has  been  thus  formulated:  Stimulus — reaction 
— liking — reinforcement.  Stimulus — reaction — dislike  or  pain- — in- 
hibition. This  is  the  early  simple  associative  memory  in  reactions 
to  stimuli. 

"8.  There  are  no  perceptible  differences  in  reactions  of  colored  and 
white  children  or  between  pairs  of  twins. 

''Ability  to  hold  the  head  erect:  This  may  be  acquired  at  the  third 
month.  Few  infants,  however,  are  able  fully  to  support  the  head  be- 
fore the  fifth  month.  Not  a  few  perfectly  normal  infants  will  not  be 
able  to  support  the  head  before  the  ninth  month. 

"Sitting  erect:  The  ability  to  sit  erect  unsupported  is  acquired  be- 
tween the  sixth  and  eighth  months. 


44  THE    PRACTICE    OF    PEDIATRICS 

"Standing:  Many  infants  will  stand  with  simply  hand  support  at 
the  tenth  month.  Exceptionally  well-developed  infants  will  stand 
with  the  hands  resting  on  some  object  at  the  eighth  month.  A  remark- 
able infant  under  my  observation  could  stand  at  the  fifth  month, 
and  walked  alone  at  the  eighth  month.  The  average  infant  walks 
alone  from  the  fourteenth  to  the  sixteenth  month.  A  few  will  be  able 
to  walk  unsupported  before  this  period,  and  other  normal  children  will 
not  walk  alone  before  the  eighteenth  or, twentieth  month. 

"Laughing:  Many  infants  may  be  made  to  laugh  from  the  third 
to  the  sixth  week. 

"Memory:  The  infant's  memory  is  very  short.  I  have  repeatedly 
known  infants  eighteen  months  of  age  who  have  entirely  forgotten  the 
mother  in  a  week. 

"  Speech:  Intelligible  words  are  formed  at  about  the  twelfth  month. 
From  the  eighteenth  month  to  the  second  year  two  or  three  words  will 
be  intelligently  put  together." 

BASKETS  FOR  EARLY  EXERCISES 

It  is  a  mistake  made  in  many  families  to  have  the  baby  in  the  arms 
a  greater  part  of  his  waking  hours.  This  practice  should  be  dis- 
couraged by  physicians,  for  when  the  child  is  held,  there  is  alwaj^s  a 
tendency  to  make  him  sit  upright  on  the  arms  or  knee  without  proper 
support.  During  the  early  months  of  life  the  vertebrae  and  vertebral 
ligaments  are  not  sufficiently  developed  to  support  the  heavy  head  and 
trunk.  If  this  thoughtlessness  on  the  part  of  parents  with  its  attend- 
ant dangers  were  explained,  there  would  be  fewer  cases  of  displaced 
scapulae  and  spinal  curvature  to  be  treated  later.  Many  cases  of  spinal 
curvature  are  the  direct  outcome  of  such  early  abuse  of  the  spinal 
column.  Still,  it  is  not  desirable  that  the  child  should  constantly 
occupy  the  crib.  A  large  clothes-basket  in  which  a  thick  blanket  and 
pillow  have  been  placed  affords  a  safe  playground  for  a  small  baby. 
For  the  first  few  months  he  will  lie  on  his  back  and  amuse  himself  in 
his  own  peculiar  way.  After  the  sixth  month,  when  he  may  be  allowed 
to  sit  up  for  a  short  time  each  day,  a  pillow  should  be  placed  behind 
his  back  for  support.  The  basket  supplies  plenty  of  room  for  toys 
and  other  means  of  entertainment.  When  the  child  begins  to  stand 
and  attempts  to  walk,  the  basket  period  is  at  an  end  and  the  exercise 
pen  (p.  767)  should  be  brought  into  use. 

CRYING 

It  is  well  for  the  young  infant  to  cry  a  little  every  day.  Muscular 
movements  involving  a  greater  part  of  the  body  accompany  the  act 
of  crying  and  furnish  exercise.  Peristalsis  is  increased,  as  is  often  evi- 
denced by  a  movement  of  the  bowels  occurring  during  crying,  particu- 
larly when  there  is  diarrhea.  In  crying,  deep  breathing  is  necessary, 
the  lungs  are  expanded,  and  the  blood  oxygenated.     The  well  baby 


SLEEP  45 

cries  when  frightened,  or  uncomfortable  from  hunger,  soiled  napkins, 
or  inflamed  buttocks.  He  cries  from  pain,  from  heat,  from  cold,  from 
unsuitable  clothing,  and  during  difficult  evacuation  of  the  bowels.  He 
also  cries  when  displeased  or  angry.  Authors  are  prone  to  refer  to  the 
diagnostic  value  of  an  infant's  cry.  It  is  my  belief  that  characteristic 
cries  are  not  to  be  depended  upon  sufficiently  to  give  them  a  differential 
diagnostic  dignity.  Children  slightly  but  painfully  ill  may  cry  inces- 
santly for  an  hour  or  two.  Thus,  with  intestinal  colic,  the  cry  is 
loud  and  continuous  until  the  child  is  relieved  or  falls  asleep  from 
exhaustion.  Earache  is  not  an  infrequent  cause.  The  habitual 
criers,  the  restless  and  vigorous,  crying,  whining  infants,  are  uncom- 
fortable. With  very  few  exceptions  the  trouble  will  be  found  in  the 
intestinal  tract.  The  well-trained,  normal  child,  whose  nourishment 
is  suitable,  is  seldom  troublesome.  When  well,  all  babies  are  natu- 
rally good-natured  and  happy  in  their  own  way.  Badly  managed, 
spoiled  infants  often  cry  vigorously  when  left  alone.  When  attention 
is  given  them,  when  they  are  taken  up  and  talked  to,  the  crying  ceases. 
This  readily  tells  us  that  pain  or  discomfort  was  not  an  element  in 
causing  the  cry.  By  these  infants,  discipline,  not  medication,  is 
needed.  The  management  of  the  habitual  crier  involves  the  relief  of 
the  condition  which  causes  the  discomfort,  or  the  most  rigid  discipline, 
when  it  is  demonstrated  that  we  are  dealing  with  a  "spoiled  infant." 

SLEEP 

The  infant  who  sleeps  well  is  almost  always  a  normal,  well-fed  baby. 
Irritability  and  sleeplessness  are  associated  with  indigestion  more 
frequently  than  with  any  other  disorder.  During  the  first  few  days  of 
life  the  sleep,  in  normal  conditions,  is  almost  unbroken,  except  when  the 
infant  is  fed.  During  the  first  month  the  infant  sleeps  about  twenty- 
two  hours  out  of  every  twenty-four;  during  the  second  and  third 
months,  from  twenty  to  twenty-two  hours.  At  the  sixth  month  the 
child  should  sleep  from  6  p.  m.  to  6  a.  m.  without  interruption  except 
for  feeding  or  nursing,  which  need  cause  very  little  disturbance.  At 
this  age  there  should  be  a  two-hour  nap  during  the  morning  and  a  two- 
hour  nap  in  the  afternoon,  although  it  is  not  well  to  have  the  baby  sleep 
after  three  o'clock  in  the  afternoon.  The  twelve-hour  night  rest  should 
be  continued  until  the  child  is  six  years  of  age.  The  day  naps  will 
gradually  be  shortened  by  the  child.  At  one  year  of  age,  one  hour  in 
the  morning  and  two  hours  in  the  afternoon  suffice.  From  the 
eighteenth  month  to  the  second  year  the  morning  nap  is  given  up. 
Afternoon  rest  for  at  least  one  and  one-half  hours  should  be  continued 
until  the  sixth  year  of  age,  and  longer  if  the  child  is  inclined  to  be 
delicate.  Regular  sleep  is  largely  a  matter  of  habit,  and  if  the  infant 
started  right  with  suitable  feedings  given  at  definite  times,  followed  by 
the  proper  period  of  sleep,  but  little  trouble  will  be  experienced.  When 
sleep  is  disturbed  and  broken,  it  means  bad  habits,  unsuitable  food, 
minor  forms  of  indigestion,  or  positive  illness  of  some  kind.     Sleep  is 


46  THE    PRACTICE    OF    PEDIATRICS 

important  for  purposes  of  growth,  not  only  in  early  infancy  but 
throughout  childhood.  Not  a  few  infants  form  habits  of  sleeping  in 
the  daytime  and  being  wakeful  at  night.  This  is  best  remedied  by 
keeping  the  baby  awake  during  the  day,  by  entertainment,  and  by 
keeping  him  in  a  well-lighted  room.  A  proper  amount  of  sleep  is  most 
essential  to  nutrition,  and  I  am  sure  that  the  satisfactory  results  which 
I  have  had  the  good  fortune  to  achieve  in  the  treatment  of  secondary 
malnutrition  and  anemia  have  been  due  in  part  to  my  insistence  that 
the  child  sleep  in  a  quiet,  darkened  room  for  two  hours  after  the  noon- 
day meal.  The  energy  expended  in  twelve  hours  by  an  active  child 
is  incalculable,  and  when  a  portion  of  this  energy  is  reserved  and  the 
body  fortified  by  rest  and  sleep  during  the  middle  of  the  day,  there  is  a 
greatly  diminished  daily  expenditure  of  strength  units. 
For  bathing  newly  born  see  p.  20. 

STOOLS 

Breast  Fed  Stools. — Infants  on  the  breast  average  two  to  three  large 
stools  daily,  although  the  number  may  range  from  one  to  five  and 
still  be  consistent  with  perfect  health.  Their  color  is  usually  of  a 
bright  yellow  or  orange  tint,  and  their  character  of  a  smooth  and 
homogeneous  consistency,  with  a  slightly  acid  reaction.  The  odor  is 
not  as  offensive  as  the  cow's  milk  stool,  as  there  is  less  putrefaction. 
of  the  protein  while  in  the  intestinal  tract.  The  bulk  or  residue 
corresponds  to  the  amount  of  ingested  food. 

Cow's  Milk  Stools. — Infants  on  the  bottle  usually  average  only  one 
stool  a  day,  which  oftentimes  is  smaller  than  that  of  the  breast-fed 
baby.  The  color  is  lighter  and  the  proportion  of  feces  to  the  amount 
of  food  taken  numerically  less  when  artificially  fed. 

Hard  Constipated  Stools. — A  hard  constipated  stool,  when  not  pro- 
duced by  any  mechanical  cause,  is  usually  due  to  a  deficiency  in  the 
food  of  either  carbohydrates  or  fats,  generally  the  latter.  Food  too  low 
in  total  solids,  leaving  an  insufficient  residue  is  also  a  cause.  Irregular 
habits  in  the  time  of  going  to  stool  and  a  lack  of  systematic  general 
training  also  play  a  part.  Sterilization  and,  to  a  lesser  degree, 
pasteurization,  make  milk  somewhat  constipating. 

Loose  Watery  Stools. — This  type  of  stool  is  seen  in  indigestion,  with 
fermentative  changes  in  the  carbohydrates  of  the  food,  and  to  a  lesser 
extent  of  the  fats.  The  stools  vary  in  color  from  a  yellow  or  yellowish 
brown  to  green.  They  are  usually  alkaline  in  reaction  and  have  a 
foul,  musty  odor.  Curds  are  seldom  seen  and  there  is  very  little 
mucus. 

Stool  in  Hard  Balls. — This  variety  of  stool  is  usually  due  to  an  excess 
of  fat  in  the  food.  The  feces  vary  in  color  from  a  light  yellow  to  a 
light  grey.  They  are  sometimes  large  and  hard  and  at  other  times 
dry,  small  and  crumbly. 

Scrambled  Egg  Stools. — Stools  of  this  order  are  seen  when  the 
carbohydrate  digestion  is  at  fault.     Bacterial  fermentations  of  the 


THE    NURSING-BOTTLE    AND    NIPPLE  47 

starch,  or  sugar  which  is  not  assimilated  by  the  organism  gives  rise 
to  loose,  green,  frothy  movements.  These  are  very  acid,  frequently 
causing  excoriations  of  the  buttocks  and  surrounding  parts. 

Mucus  in  Stools. — Mucus  in  stools  denotes  a  form  of  irrita.tion  in 
the  digestive  tract  which  gives  rise  to  an  excessive  secretion  from  the 
mucous  glands  of  the  intestine.  It  is  almost  invariably  present  in 
abnormal  stools.  Mucus  and  feces  intimately  mixed  indicates  the 
source  of  the  trouble  to  be  in  the  small  intestines;  or  if  on  the  outside 
of  a  constipated  stool,  from  the  rectum;  if  in  combination  with  a  clay- 
colored  stool,  from  the  duodenum. 

Blood  in  Stools. — In  older  children,  blood  in- 
timately mixed  with  the  stools  would  suggest  an 
ulceration  of  the  stomach  or  small  intestine.  When 
on  the  outside  of  a  constipated  stool,  it  may  indicate 
a  rectal  lesion,  an  anal  fissure,  diverticuli,  or  in- 
complete intussusception.  A  stool  composed  of 
blood  and  mucus  without  fecal  material  is  very 
characteristic  of  intussusception.  Melsena  neona- 
torum or  hemorrhage  of  the  newly-born  is  char- 
acterized by  a  profuse  discharge  of  blood  from  the 
rectum. 

Curds  in  Stools. — This  is  one  of  the  most  frequent 
of  the  abnormal  constituents  of  infant's  stools. 
Two  kinds  are  found :  one  firm  and  tough  and  very 
hard  to  press  out,  insoluble  in  ether,  varying  in  size 
from  a  small  pea  to  a  hickory  nut,  with  a  brown  or 
greenish  coating,  but  white  on  cross-section,  which 
is  known  as  a  protein  curd;  the  other  is  composed       j'l|P  I 

of  fat,  easily  pressed  out,  does  not  sink  in  water 
varies  in  color  from  white  or  yellow  to  green,  is 
somewhat  soluble  in  ether,  and  is  not  hardened  by 
formalins. 

THE  NURSING-BOTTLE  AND  NIPPLE 

There  are  two   requirements   that   a  nursing-      ^    V    --         / 

bottle  must  fulfil :  it  must  have  a  capacity  sufficient     |^^, ^  ^^ 

for  one  full  feeding  and  it  must  be  so  constructed  -p.  „  ^ 
as  to  be  readily  cleansed.  The  oval  bottle  with  ^fle  and  nim)l'e°  ' 
rounded  edges  answers  best.  These  may  be  ob- 
tained in  sizes  of  from  three  to  nine  ounces.  As  many  bottles  are 
needed  as  there  are  feedings  in  twenty-four  hours.  The  bottles  should 
be  boiled  once  a  day,  scrubbed  with  a  stiff  brush  with  hot  borax  water, 
and  remain  in  the  borax  water  until  needed.  Two  teaspoonfuls  of 
borax  to  a  pint  of  water  is  the  strength  usually  used.  Before  using, 
bottles  should  be  rinsed  in  plain  boiled  water.  The  straight  black 
nipple  (Fig.  3)  is  also  preferred,  for  the  reason  that  it  can  be  turned 
inside  out  and  easily  cleansed.  A  nipple  which  cannot  be  turned 
should  never  be  used.     After  use,  the  nipple  should  be  turned  and 


48  THE    PRACTICE    OF    PEDIATRICS 

scrubbed  with  a  stiff  brush  and  borax  water — a  tablespoonful  of  borax 
to  a  pint  of  water.  When  not  in  use,  the  nipple  should  be  kept  in 
borax  water.  Before  being  placed  on  the  bottle,  it  should  be  rinsed  in 
boiled  water.  The  nipple  should  be  boiled  once  a  day.  The  blind 
nipples — those  without  holes — are  the  best.  Holes  of  the  required 
size  may  be  made  with  a  red-hot  cambric  needle. 

Substitute  Breast-feeding;  Artificial  Feeding 

A  considerable  number  of  the  young  of  the  human  race  are  de- 
prived of  the  natural  means  of  nutrition,  the  milk  of  the  mother. 
For  comparatively  few  is  a  wet-nurse  available.  While  in  proportion 
to  the  children  born  more  mothers  are  nursing  their  infants  now  than 
formerly,  nevertheless  every  year  thousands  of  infants  are  brought  into 
the  world  who  have  to  be  nourished  by  other  means  than  human  milk. 
The  fact  that  an  immense  number  of  deaths  occur  every  year  among 
these  infants  because  of  defective  nutrition  speaks  for  itself. 

Nutritional  Errors. — Mortality  statistics  give  a  very  inadequate 
idea  as  to  the  part  played  by  nutritional  errors  in  the  young,  for  the 
reason  that  in  many  instances  such  errors  are  not  the  direct  or  perhaps 
the  immediate  cause  of  death,  and  for  this  reason  their  influence  does 
not  appear  in  mortality  statistics.  As  elsewhere  pointed  out,  and 
dwelt  upon  at  length  in  this  work,  in  disease  of  any  nature  a  child's 
resistance  is  a  factor  of  paramount  importance.  With  defective 
nutrition,  resistance  is  invariably  below  the  normal.  Many  of  the 
infants  who  die  from  the  intestinal  diseases  of  summer,  from  grip,  from 
tuberculosis,  or  from  infectious  diseases,  suffer  from  defective,  nutri- 
tion in  different  degrees  of  severity  before  the  immediate  cause  of 
death  exists. 

The  Needs  of  the  Patient  Paramount. — As  nutrition  deals  directly 
with  questions  of  life  and  death,  it  is  not  surprising  that  volumes  have 
been  written  on  the  subject,  but  it  is  surprising  that  the  fundamental 
principles  of  infants'  nutrition  are  so  little  understood.  This  is  due  in 
part  to  the  fact  that  writers  and  teachers  of  infant-feeding,  in  their 
efforts  to  be  scientific  or  ultra-scientific,  have  lost  sight  of  the  point 
that  there  is  a  patient  as  well  as  a  pupil  to  be  considered,  and  that  not  a 
few  teachers  with  their  algebraic  or  otherwise  intricate  formulas  do 
little  but  obstruct  the  progress  of  rational  feeding  by  making  a  readily 
comprehended  subject  impossible  to  many.  Another  common  error 
is  in  not  distinguishing  between  children — the  rich  and  the  poor,  the 
sick  and  the  well.  A  child  with  malnutrition,  with  marasmus,  or  with 
a  temporarily  disordered  digestion  is  by  no  means  a  well  baby,  and 
when  he  is  given  food  suitable  only  for  the  well,  his  condition  very 
naturally  is  not  improved. 

Environment. — In  feeding  an  infant,  several  predominant  factors 
must  be  considered.  The  influences  of  environment  are  most  important. 
The  infant  in  a  children's  institution  has  to  be  fed  differently  from 
one  who  comes  to  a  dispensary  for  treatment,  and  both  must  be  fed 


cow's    MILK  49 

differently  in  summer  than  in  winter.  The  child  of  well-to-do,  intelli- 
gent parents  is  fed  still  differently.  There  are  no  hard  and  fast  lines 
in  infant  feeding  other  than  that  there  must  be  an  ample  supply  of  such 
nourishment  as  the  child  can  digest  and  thrive  upon.  Cow's  milk  is 
used  as  the  basis  of  infant's  food,  for  the  reason  that  it  is  ordinarily 
readily  adapted  to  the  child's  digestion  and  is  the  most  available 
substitute  for  human  milk. 

Successful  Substitute  Feeding. — Successful  substitute  feeding  of 
infants  consists,  then,  in  giving  something  upon  which  the  child  can 
live  and  thrive,  and  when,  in  addition,  this  "something"  supplies  the 
nutrition  which  nature  demands,  it  constitutes  scientific  infant-feeding, 
whatever  the  source  of  the  nutriment.  Cow's  milk  is  just  as  fully  an 
unnatural  food  for  an  infant  as  is  barley  or  rice  gruel  or  the  milk  of  the 
goat  or  the  ass;  and  cow's  milk  only  is  used,  as  already  mentioned, 
because  in  a  great  majority  of  cases  it  answers  the  given  purpose  better 
than  does  any  other  food,  in  that  it  furnishes  in  an  available  form  the 
nearest  approach  to  the  nutritional  elements  required.  From  an 
analysis  of  many  human  milks  we  know  what  should  constitute  a 
child's  food.  Cow's  milk,  however,  differs  from  human  milk  in  im- 
portant features. 

COWS  MILK 

As  cow's  milk  furnishes  the  most  available  basis  of  nutrition  for 
the  infant  who  is  deprived  of  the  mother's  milk,  it  is  essential  in  order 
to  secure  the  best  results  from  its  use  as  an  infant  food,  that  it  contain' 
total  solids  between  12  and  13  per  cent,  and  that  the  solids  be  repre- 
sented in  the  nutritional  elements  in  somewhat  the  following  pro- 
portions : 

Fat 3.5      to  4     per  cent. 

Sugar 4         to  4.5  " 

Total  proteid 3.5      to  4 

Ash 0.7      to  0.9         " 

Specific  gravity 1.028  to  1.033 

In  order  that  the  milk  may  be  of  a  fairly  constant  strength,  herd- 
milk  is  to  be  preferred  to  the  product  of  one  or  two  cows,  as  the  quality 
of  the  latter  may  vary  considerably  from  day  to  day.  It  has  been 
demonstrated  that  the  best  cows  for  this  purpose  are  what  are  known 
as  "grade  cows,"  that  is,  not  pure  bred.  Such  cows  thrive  better,  are 
more  easily  kept  healthy,  and  are  more  uniform  in  the  nutritional 
equivalent  of  their  milk-supply  than  are  high-class  registered  herds  of 
the  Alderney  or  Jersey  strain. 

There  are  several  proteids  of  cow's  milk,  of  which  the  most  impor- 
tant and  best  known  are  casein,  which  forms  the  curd,  and  lactalbumin, 
the  proportion  being  about  three  parts  casein  to  one  part  of  lactal- 
bumin. In  mixed  milk  from  several  cows  this  proportion  is  by  no 
means  constant.  The  sugar  of  cow's  milk  is  lactose,  which  is  less 
sweet  to  the  taste  than  cane-sugar  or  granulated  sugar  or  maltose 
derived  from  starch.  That  cow's  milk  shall  contain  a  certain  quantity 
4 


50  THE    PRACTICE    OF    PEDIATRICS 

of  total  solids,  and  that  it  shall  be  of  a  specific  gravity  within  certain 
limits,  is  necessary  in  order  that  it  may  supply  nourishment  to  the 
child.  Another  most  important  feature  to  be  taken  into  consideration 
is  cleanliness,  which  naturally  brings  us  to  a  consideration  of  the 
bacteriology  of  milk — a  large  subject  which  can  be  but  briefly  referred 
to  here.  Milk  fresh  from  the  udder  contains  very  few  bacteria,  parti- 
cularly if  the  first  two  or  three  jets  from  each  teat  are  discarded.  The 
time  for  bacterial  contamination  is  during  the  milking  and  while  the 
milk  remains  in  the  stable.  Certain  forms  of  bacteria  are  harmless, 
and  it  is  impossible  to  have  a  milk  absolutely  free  from  bacteria. 
What  we  need  to  know  is  how  dangerous  bacteria  get  into  the  milk, 
and  how  they  cause  changes  that  may  convert  it  into  a  poison  of 
greater  or  less  virulence. 

Harmless  Bacteria. — The  souring  of  milk  is  the  result  of  the  pres- 
ence of  bacteria  which  produce  changes  in  the  sugar-of-milk,  with  the 
formation  of  lactic  acid.  The  "turning"  of  milk  during  a  thunder- 
shower  is  due  to  certain  changes  in  the  atmosphere  that  aid  in  the 
development  of  the  bacteria  which  convert  lactose  into  lactic  acid. 

Harmful  Bacteria. — Bacteria  of  decomposition,  under  conditions 
favorable  to  their  growth,  attack  the  proteid  constituents  of  the  milk, 
producing  putrefactive  changes  with  evolution  of  poisons  which  may  be 
of  the  greatest  virulence.  The  putrefactive  bacteria  are  always  pres- 
ent in  stables  where  manure  is  allowed  to  collect  and  where  cleanliness 
is  not  observed.  When  we  remember  what  a  culture-field  milk  affords 
to  bacteria,  and  when  we  see  the  manure  and  the  surroundings  in 
which  milk  is  often  drawn,  it  is  not  surprising  that  the  milk  should 
contain  many  millions  of  bacteria  to  a  cubic  centimeter.  They  may 
enter  the  milk  from  the  dust  in  the  stable, — a  very  fruitful  source, — 
or  they  may  find  entrance  from  the  milker's  hands  or  from  droppings 
of  fine  particles  of  manure  from  the  belly  of  the  cow.  Bacteria  from 
these  sources  are  among  the  most  dangerous  forms  found  in  milk. 
When  bacteria  once  gain  entrance  into  the  milk,  their  growth  is  most 
rapid. 

Market  Milk. — The  legal  standards  for  pure  milk  in  most  instances 
relate  only  to  the  chemical  composition  of  the  milk.  The  laws  of 
most  of  the  States  call  for  12  per  cent,  of  total  solids,  and  at  least  3  per 
cent,  of  fat.  If  the  milk  contains  less  than  these  percentages,  it  is 
considered  impure,  even  if  it  is  just  as  it  was  when  it  left  the  cow's 
udder.  Some  cows  give  milk  considerably  below  this  standard.  The 
chemical  analysis  of  milk  does  not  show  whether  it  is  suitable  for  use 
as  an  infant  food,  this  point  being  decided  according  to  its  freshness 
and  the  care  with  which  it  has  been  handled  with  reference  to  the 
exclusion  of  bacteria  and  the  prevention  of  their  growth.  The  produc- 
tion of  clean,  safe  milk  is  expensive.  It  costs  at  least  two  cents  a  quart 
to  produce  milk,  without  allowing  anything  for  the  labor  of  caring  for 
the  cows.  The  milk  must  be  carried  to  the  consumer,  which  is  also 
expensive. 

Certified  Milk. — The  best  grade  of  milk,  and  the  one  which  should 


cow's   MILK  51 

be  used  in  feeding  infants  whenever  possible  is  known  as  "certified 
milk,"  and  is  produced  under  the  direction  of  what  is  known  as  a  "  milk 
commission."  The  establishing  of  "milk  commissions"  in  different 
cities  throughout  the  country  has  been  the  means  of  securing  a  much 
better  milk-supply  than  was  formerly  possible,  and  has  unquestionably 
been  instrumental  in  saving  thousands  of  lives.  To  Dr.  H.  L.  Coit,  of 
Newark,  N.  J.,  is  due  the  credit  of  organizing  the  first  milk  commission. 
Certified  milk  must  conform  to  certain  standards  as  to  its  nutritional 
value  and  as  to  the  number  of  bacteria  per  cubic  centimeter.  These 
standards  are  established  by  a  committee  of  medical  men  who  com- 
pose the  milk  commission,  and  who  have  complete  control  of  the  dairy 
and  its  entire  output. 

The  Milk  Commission  of  the  New  York  County  Medical  Society 
requires  a  standard  of  milk  not  containing  over  10,000  bacteria  in  a 
cubic  centimeter.  When  a  dairyman  has  shown  to  the  satisfaction  of 
•the  Commission  that  he  can  produce  a  milk  up  to  the  required  stand- 
ard, he  is  allowed  to  attach  to  his  bottles  milk  labels  furnished  by  the 
Commission  certifying  to  that  fact.  Milk  thus  "certified"  is  taken 
from  the  delivery  wagon  from  time  to  time  and  subjected  to  examina- 
tion by  their  bacteriologist  in  order  to  determine  whether  it  conforms 
to  the  requirements  of  the  Commission.  In  order  to  show  the  care 
and  supervision  necessary  for  the  production  of  certified  milk,  the 
requirements  of  the  Milk  Commission  of  the  New  York  County 
Medical  Society  for  the  Production  of  "certified  milk"  are  given  in 
full.* 

"The  most  practicable  standard  for  the  estimation  of  cleanliness  in 
the  handling  and  care  of  milk  is  its  relative  freedom  from  bacteria. 
The  Commission  has  tentatively  fixed  upon  a  maximum  of  10,000 
germs  of  all  kinds  per  cubic  centimeter  of  milk,  which  must  not  be 
exceeded  in  order  to  obtain  the  indorsement  of  the  Commission.  This 
standard  must  be  attained  solely  by  measures  directed  toward  scrupu- 
lous cleanliness,  proper  cooling,  and  prompt  delivery.  The  milk 
certified  by  the  Commission  must  contain  not  less  than  4  per  cent,  of 
butter-fat  on  the  average,  and  must  possess  all  the  other  characteristics 
of  pure,  wholesome  milk. 

"In  order  that  dealers  who  incur  the  expense  and  take  the  pre- 
cautions necessary  to  furnish  a  truly  clean  and  wholesome  milk  may 
have  some  suitable  means  of  bringing  these  facts  before  the  public,  the 
Commission  offers  them  the  right  to  use  caps  on  their  milk-jars  stamped 
with  the  words:  'Certified  by  the  New  York  County  Medical  Society 
Milk  Commission.' 

"Rules  for  the  Producer. — 1.  The  Barnyard. — The  barnyard 
should  be  free  from  manure  and  well  drained,  so  that  it  may  not  har- 
bor stagnant  water.  The  manure  which  collects  each  day  should  not 
be  piled  close  to  the  barn,  but  should  be  taken  several  hundred  feet 
away.  If  these  rules  are  observed  not  only  will  the  barnyard  be  free 
from  objectionable  smell,  which  is  always  an  injury  to  the  milk,  but 
*Chapm:  "Infant  Feeding." 


52  THE    PRACTICE    OF    PEDIATRICS 

the  number  of  flies  in  summer  will  be  considerably  diminished.  These 
flies,  in  themselves,  are  an  element  of  danger,  for  they  are  fond  of  both 
filth  and  milk,  and  are  liable  to  get  into  the  milk  after  having  soiled 
their  bodies  and  legs  in  recently  visited  filth,  thus  carrying  it  into  the 
milk.  Flies  also  irritate  cows,  and  by  making  them  nervous  reduce  the 
amount  of  their  milk. 

"2.  The  Stable. — In  the  stable  the  principles  of  cleanliness  must 
be  strictly  observed.  The  room  in  which  the  cows  are  milked  should 
have  no  storage  loft  above  it;  where  this  is  not  feasible,  the  floor  of  the 
loft  should  be  tight,  to  prevent  the  sifting  of  dust  into  the  stable 
beneath.  The  stable  should  be  well  ventilated,  lighted,  and  drained, 
and  should  have  tight  floors,  preferably  of  cement.  They  should  be 
whitewashed  inside  at  least  twice  a  year,  and  the  air  should  always  be 
fresh  and  without  bad  odor.  A  sufficient  number  of  lanterns  should 
be  provided  to  enable  the  necessary  work  to  be  done  properly  during 
dark  hours.  There  should  be  an  adequate  water-supply  and  the. 
necessary  wash-basins,  soap,  and  towels.  The  manure  should  be 
removed  from  the  stalls  twice  daily,  except  when  the  cows  are  outside 
in  the  fields  the  entire  time  between  the  morning  and  afternoon  milk- 
ings.  The  manure  gutter  must  be  kept  in  a  sanitary  condition,  and 
all  sweeping  and  cleaning  must  be  finished  at  least  twenty-minutes 
before  milking,  so  that  at  that  time  the  air  may  be  free  from  dust. 

"3.  Water-supply. — The  whole  premises  used  for  dairy  purposes, 
as  well  as  the  barn,  must  have  a  supply  of  water,  absolutely  free  from 
any  danger  of  pollution  with  animal  matter,  sufficiently  abundant  for 
all  purposes,  and  easy  of  access. 

"4.  The  Cows. — The  cows  should  be  examined  at  least  twice  a  year 
by  a  skilled  veterinarian.  Any  animal  suspected  of  being  in  bad  health 
must  be  promptly  removed  from  the  herd,  and  her  milk  rejected. 
Never  add  an  animal  to  the  herd  until  it  has  been  tested  for  tuberculosis 
and  it  is  certain  that  it  is  free  from  disease.  Do  not  allow  the  cows  to 
be  excited  by  hard  driving,  abuse,  loud  talking,  or  any  unnecessary  dis- 
turbance. Do  not  allow  any  strongly  flavored  food,  like  garlic,  which 
will  affect  the  flavor  of  the  milk,  to  be  eaten  by  the  cows. 

"Groom  the  entire  body  of  the  cow  daily.  Before  each  milking 
wipe  the  udder  with  a  clean  damp  cloth,  and,  when  necessary,  wash  it 
with  soap  and  clean  water  and  wipe  it  dry  with  a  clean  towel.  Never 
leave  the  udder  wet,  and  be  sure  that  the  water  and  towel  used  are 
clean.  If  the  hair  in  the  region  of  the  udder  is  long  and  not  easily  kept 
clean,  it  should  be  clipped.  The  cows  must  not  be  allowed  to  lie  down 
after  being  cleaned  for  milking,  until  the  milking  is  finished.  A  chain 
or  rope  must  be  stretched  under  the  neck  to  prevent  this. 

"All  milk  from  cows  sixty  days  before  and  ten  days  after  calving 
must  be  rejected. 

"5.  The  Milkers. — The  milker  should  be  personally  clean.  He 
should  neither  have  nor  come  into  contact  with  any  contagious  disease 
while  employed  in  milking  or  handling  milk.  In  .case  of  any  such 
illness  in  the  person  or  family  of  any  employee  in  the  dairy,  such  em- 


cow's   MILK  53 

ployee  must  absent  himself  from  the  dairy  until  a  physician  certifies 
that  it  is  safe  for  him  to  return. 

"Before  milking,  the  hands  should  be  thoroughly  washed  in  warm 
water  with  soap  and  a  nail-brush  and  well  dried  with  a  clean  towel. 
On  no  account  should  the  hands  be  wet  during  the  milking. 

"  The  milking  should  be  done  regularly  at  the  same  hour  morning 
and  evening,  and  in  a  quiet,  thorough  manner.  Light-colored,  wash- 
able outer  garments  should  be  worn  during  milking.  They  should  be 
clean  and  dry,  and  when  not  in  use  for  this  purpose,  should  be  kept  in  a 
clean  place  protected  from  dust.  Milking-stools  must  be  kept  clean. 
Iron  stools  painted  white  are  recommended. 

*'  6.  Helpers,  Other  than  Milkers. — All  persons  engaged  in  the  stable 
and  dairy  should  be  reliable  and  intelligent.  Children  under  twelve 
years  should  not  be  allowed  in  the  stable  during  milking,  since  in  their 
ignorance  they  may  do  harm,  and  from  their  liability  to  contagious 
diseases  they  are  more  apt  than  older  persons  to  transmit  them 
through  the  milk. 

"7.  Small  Animals. — Cats  and  dogs  must  be  excluded  from  the 
stable  during  the  time  of  milking. 

''8.  The  Milk. — The  first  few  streams  from  each  teat  should  be  dis- 
carded, in  order  to  free  the  milk-ducts  from  milk  that  has  remained  in 
them  for  some  time  and  in  which  bacteria  are  sure  to  have  multiplied 
greatly.  If,  in  any  milking,  a  part  of  the  milk  is  bloody  or  stringy  or 
unnatural  in  appearance,  the  whole  quantity  of  milk  yielded  by  that 
animal  must  be  rejected.  If  any  accident  occurs  by  which  the  milk 
in  a  pail  becomes  dirty,  do  not  try  to  remove  the  dirt  by  straining, 
but  reject  all  the  milk  and  cleanse  the  pail.  The  milk-pails  used  should 
have  an  opening  not  exceeding  eight  inches  in  diameter. 

"Remove  the  milk  of  each  cow  from  the  stable,  immediately  after 
it  is  obtained,  to  a  clean  room,  and  strain  it  through  a  sterilized  strainer. 

"The  rapid  cooling  of  milk  is  a  matter  of  great  importance.  The 
milk  should  be  cooled  to  45°F.  within  one  hour.  Aeration  of  pure  milk 
beyond  that  obtained  in  milking  is  unnecessary. 

"All  dairy  utensils,  including  bottles,  must  be  thoroughly  cleansed 
and  sterilized.  This  can  be  done  by  first  thoroughly  rinsing  in  warm 
water,  then  washing  with  a  brush  and  soap  or  other  alkaline  cleansing 
material  and  hot  water,  and  thoroughly  rinsing.  After  this  cleansing, 
they  should  be  sterilized  with  boiling  water  or  steam,  and  then  kept 
inverted  in  a  place  free  from  dust. 

"9.  The  Dairy. — The  room  or  rooms  where  the  bottles,  milk-pails, 
strainers,  and  other  utensils  are  cleaned  and  sterilized  should  be  sepa- 
rated somewhat  from  the  house,  or  when  this  is  impossible,  have  at 
least  a  separate  entrance,  and  be  used  only  for  dairy  purposes,  so  as  to 
lessen  the  danger  of  transmitting  through  the  milk  contagious  diseases 
which  may  occur  in  the  home. 

"Bottles,  after  filling,  must  be  closed  with  sterilized  discs  and 
capped  so  as  to  keep  all  dirt  and  dust  from  the  inner  surface  of  the 
neck  and  mouth  of  the  bottle. 


54  THE    PRACTICE    OF    PEDIATRICS 

"  10.  Examination  of  the  Milk  and  Dairy  Inspection. — In  order  that 
the  dealers  and  the  Commission  may  be  kept  informed  of  the  character 
of  the  milk,  specimens  taken  at  random  from  the  day's  supply  must  be 
sent  weekly  to  the  Research  Laboratory  of  the  Health  Department, 
where  examinations  will  be  made  by  experts  for  the  Commission,  the 
Health  Department  having  given  the  use  of  its  laboratories  for  this 
purpose. 

"The  Commission  reserves  to  itself  the  right  to  make  inspections  of 
certified  farms  at  any  time  and  to  take  specimens  of  milk  for  examina- 
tion. It  also  reserves  the  right  to  change  its  standards  in  any  reason- 
able manner  upon  due  notice  being  given  the  dealers." 

Naturally,  milk  produced  in  this  way  is  more  expensive  than  when 
little  or  no  care  is  used,  more  help  is  required,  and  help  of  a  more  ex- 
pensive type.  Certified  milk,  or  its  equivalent,  is  sold  in  New  York 
City  at  prices  ranging  from  15  to  20  cents  a  quart. 

Examination  of  Cow's  Milk. — In  the  use  of  cow's  milk,  as  in  that 
of  human  milk,  a  chemical  analysis  is  necessary,  in  order  to  know 
accurately  the  nutritional  elements.  The  specific  gravity  varies  from 
1.029  to  1.035.  Milk  is  acid  in  reaction  to  phenolphthalein,  and  may 
be  neutral  to  litmus.  The  Babcock  milk-test  machine  is  what  is 
generally  employed  in  examining  cow's  milk  in  laboratories  and  insti- 
tutions. The  test  consists  in  mixing  the  milk  with  strong  sulphuric 
acid,  which  dissolves  the  proteids  and  liberates  the  fat,  the  quantity  of 
which  is  read  off  from  the  graduated  neck  of  the  bottle  used  in  mix- 
ing the  milk  and  acid.  Only  the  fat  is  determined  in  this  way.  Know- 
ing the  fat  and  the  specific  gravity,  one  may  readily  determine  the 
solids  other  than  fat  by  adding  to  one-fourth  of  the  specific  gravity, 
reading  to  the  right  of  the  decimal  point,  one-fourth  of  the  percentage 
of  fat. 

MODIFIED  MILK 

At  one  time  it  was  thought  that,  by  changing  the  percentage  com- 
position of  cow's  milk  and  altering  the  reaction,  it  could  be  made  prac- 
tically identical  with  human  milk,  and  the  term  ''modified  milk"  was 
applied  to  cow's  milk  so  manipulated.  A  great  variety  of  manipula- 
tions of  cow's  milk  has  been  introduced,  which  often  differ  greatly  in 
the  principles  involved.  Yet  to  products  of  all  these  different  manipu- 
lations the  term  "modified  milk"  is  applied.  It  may  mean  any  one 
of  a  dozen  or  more  different  products.  Cow's  milk  diluted  with 
water  and  given  as  a  food  to  an  infant  is  called  "modified  milk." 
When  sugar,  cereal  gruel,  lime-water,  bicarbonate  of  sodium,  or  citrate 
of  sodium  is  added,  it  is  still  "modified  milk."  When  a  prescription 
is  sent  to  the  laboratory  calling  for  definite  amounts  of  fat,  sugar,  and 
proteids,  the  product  furnished  is  "modified  milk."  When  a  mother 
is  told  to  use  a  definite  amount  of  cream,  milk,  sugar,  and  water, 
"modified  milk"  is  also  the  outcome. 

As  a  matter  of  fact,  successful  infant-feeding  consists  in  what  I 
have  termed  "milk  adaptation,"  that  is,  modifying  the  milk  to  suit 


MODIFIED    MILK  55 

the  case  in  hand.  The  routine  prescriber  is  content  to  prescribe 
"modified  milk,"  that  which  was  originally  supposed  to  be  an  imitation 
of  human  milk.  The  best-informed  prescriber  uses  "an  adapted 
modified  milk"  which  he  decides  is  indicated. 

The  analysis  of  mixed  dairy  milk  shows  it  to  contain  approximately : 

4.0  per  cent.  fat. 

4.0  per  cent,  sugar. 

3.5  per  cent,  total  proteid. 

Human  milk  contains  approximately: 

4.0  per  cent.  fat. 

7.0  per  cent,  sugar. 

1.5  per  cent,  total  proteid. 

The  Aim  of  Milk  Modification. — The  first  aim  in  the  modification 
is  to  make  the  chief  nutritional  elements  in  the  food  prepared  from 
cow's  milk  correspond  grossly  to  the  nutritional  elements  in  the 
human  milk.  The  proteid  must  be  reduced,  the  sugar  increased,  and 
the  fat  reduced  even  slightly  below  that  usually  found  in  mother's 
milk,  as  the  child's  digestive  capacity  for  cow's-milk  fat  is  less  by  from 
15  to  25  per  cent,  than  it  is  for  human  milk. 

The  Proteid. — The  proteid  element  in  an  infant's  food  is  its  chief 
nutritional  content.  This  has  to  be  reduced  to  approximately  the  pro- 
portions that  exist  in  human  milk,  and  the  change  can  be  accom- 
plished only  by  dilution.  The  diluent  may  be  plain  water  or  it  may 
be  a  cereal  gruel.     The  average  cow's  milk  contains,  as  just  mentioned: 

4.0  per  cent.  fat. 

4.0  per  cent,  sugar. 

3.5  per  cent,  total  proteid. 

If  8  ounces  of  milk  is  mixed  with  8  ounces  of  water,  we  get  a  pint  mix- 
ture with  an  approximate  nutritional  equivalent  of: 

2.0    per  cent.  fat. 

2.0    per  cent,  sugar. 

1.75  per  cent,  total  proteid. 

If  4  ounces  of  milk  is  mixed  with  12  ounces  of  water,  we  have  a  16- 
ounce  mixture  with  an  approximate  nutritional  equivalent  of: 

1.0  per  cent.  fat. 

1.0  per  cent,  sugar. 

0.9  per  cent,  total  proteid. 

If  6  ounces  of  milk  is  mixed  with  10  ounces  of  water,  a  16-ounce  mix- 
ture is  produced  with  an  approximate  nutritional  equivalent  of : 


1.5  per  cent.  fat. 

1.5  per  cent,  sugar. 

1.3  per  cent,  total  proteid. 


56  THE    PRACTICE    OF    PEDIATRICS 

By  this  simple  dilution  with  water  the  desired  proteid  content  of  the 
food  may  be  arrived  at. 

The  Sugar. — For  nourishment  for  an  infant,  however,  the  mixture 
is  weak  in  fat  and  very  weak  in  sugar.  The  sugar  content  is  increased 
by  the  addition  of  milk-sugar  or  cane-sugar.  It  will  be  remembered 
that  in  human  milk  there  is  a  sugar  content  of  7  per  cent.  The  com- 
bination of  full  cow's  milk  and  water  as  above  gives  a  sugar  content  of 
2  per  cent,  or  less,  so  that  sufficient  sugar  must  be  added  to  make  the 
increase  approximately  7  per  cent.  What  is  necessary,  then,  is  to  in- 
crease the  sugar  content  5  per  cent.  A  1  per  cent,  sugar  and  water 
mixture  would  contain  approximately  5  grains  of  sugar  to  the  ounce. 
A  6  per  cent,  sugar  mixture  would  contain  30  grains  to  the  ounce,  and 
as  our  dealings  are  with  a  16-ounce  mixture,  we  require  an  addition 
of  16  times  30  grains  of  sugar-of-milk,  or  480  grains,  so  that  if  we  direct 
that  a  pint  mixture  contain  6  ounces  of  a  4-4-3.50  milk,  10  ounces 
water,  1  ounce  milk-sugar,  there  would  be  an  approximate  nutritional 
equivalent  of: 

1.5  per  cent.  fat. 

7.5  per  cent,  sugar. 

1.3  per  cent,  total  proteid. 

Or  if  the  mixture  were  4  ounces  milk,  12  ounces  water,  1  ounce  milk- 
sugar,  there  would  be  an  approximate  nutritional  equivalent  of: 

1.0  per  cent.  fat. 

7.0  per  cent,  sugar. 

0.9  per  cent,  total  proteid. 

The  Fat. — While  a  child  of  from  two  to  four  months  might  thrive 
on  the  above  formulas,  the  fat  is  obviously  deficient  and  must  be 
increased.  This  is  accomplished  by  the  use  of  cream.  Cream  of  the 
same  age  as  the  milk  should  be  used.  When  this  method  of  feeding  is 
carried  out,  in  order  to  secure  a  suitable  cream,  a  quart  bottle  of  milk 
from  a  mixed  herd  of  grade  cows  is  allowed  to  stand  at  a  temperature 
of  40°  or  50°F.  for  five  hours,  when  a  cream  which  will  be  referred  to  as 
"gravity  cream"  (p.  73)  will  be  produced  of  the  approximate  strength 
of: 

16.0  per  cent,  butter-fat. 

3.2  per  cent,  sugar. 

3.2  per  cent,  total  proteid. 

These  were  the  percentages  obtained  in  an  analysis  made  for  me  from 
the  Walker-Gordon  Laboratory  milk,  which  is  produced  by  grade  cows 
and  has  an  average  milk  strength  as  regards  the  nutritional  elements, 
and  may  therefore  be  taken  as  a  guide  in  using  gravity  cream  for  infant- 
feeding.  Cream  from  well-fed  Jersey  cows  procured  in  this  way  will 
contain  from  20  to  24  per  cent,  of  fat.  One  ounce  of  gravity  cream 
with  15  ounces  of  water  gives  a  pint  mixture  with  a  nutritional  equiva- 
lent of: 


MODIFIED    MILK 


57 


1.0  per  cent.  fat. 

0.2  per  cent,  sugar. 

0.2  per  cent,  total  proteid. 

Two  ounces  of  gravity  cream  and  14  ounces  of  water  give  an  approxi- 
mate nutritional  equivalent  of: 

2.0  per  cent.  fat. 

0.4  per  cent,  sugar. 

0.4  per  cent,  total  proteid. 
We  now  wish  by  using  gravity  cream  (see  p.  73) 
to  raise  the  fat  in  the  milk  and  sugar-water  mixtures 
given  above.  In  using  the  cream,  all  must  be  removed 
and  mixed,  as  the  upper  layers  in  the  bottle  are  much 
richer  in  fat  than  those  nearer  the  milk.  For  this 
skimming  process  the  Chapin  dipper  (Fig.  4)  is  em- 
ployed. Milk  which  is  rapidly  cooled  immediately 
after  being  drawn  and  kept  at  a  temperature  of  50°F. 
or  lower  may  be  skimmed  at  the  end  of  five  hours, 
when  all  the  cream  that  will  rise  will  have  done  so. 

ILLUSTRATIVE  FOOD  FORMULAS 


Gravity  cream 1  ounce 

Milk 4  ounces 

Milk-sugar 1  ounce 

Water 11  ounces 

Gravity  cream 2  ounces 

Wilk 4  ounces 

Milk-sugar 1  ounce 

Mater 10  ounces 


Approximate  Percentage 
Equivalent 

Fat 2.0 

Sugar 7.2 

Total  proteid 1.1 

Approximate  Percentage 
Equivalent 

Fat 3.0 

Sugar 7.4 

Total  proteid 1.3 


Fig.  4.— Self- 
filling  and  empty- 
ing Chapin  dipper. 


In  the  event  of  a  weak  proteid  digestion  in  a  young 
baby,  gravity  cream  alone  may  be  used  temporarily; 
thus  3  ounces  cream,  1  ounce  milk-sugar,  12  ounces 
water,  1  ounce  lime-water,  which  mixture  gives  an 
approximate  nutritional  equivalent  of: 

3.0  per  cent.  fat. 

6.6  per  cent,  sugar. 

0.6  per  cent,  total  proteid. 

Of  if  a  weaker  food  is  desired  for  a  younger  infant,  we  may  use  2  ounces 
gravity  cream,  1  ounce  milk-sugar,  133^^  ounces  water,  3-^  ounce  lime- 
water,  which  mixture  gives  an  approximate  equivalent  of: 

2.0  per  cent.  fat. 

6.4  per  cent,  sugar. 

0.4  per  cent,  total  proteid. 

In  the  event  of  a  good  proteid  digestion  and  poor  fat  digestion,  full 
milk  along  with  sugar  and  water  should  be  used;  thus  53^  ounces  milk, 
10  ounces  water,  1  ounce  milk-sugar,  1%  ounces  lime-water,  which 
mixture  gives  an  approximate  equivalent  of: 


58  THE    PRACTICE    OF    PEDIATRICS 

1.33  per  cent.  fat. 

7.33  per  cent,  sugar. 

1.17  per  cent,  total  proteid. 

Average  skimmed  milk  with  the  gravity  cream  removed  contains  about 
1  per  cent,  fat,  3.5  per  cent,  sugar,  and  3  per  cent,  proteid.  If  for  any 
reason  a  particularly  weak  fat  food  is  required,  skimmed  milk  may  be 
used:  53-^ ounces  skimmed  milk,  9  ounces  water,  1  ounce  milk-sugar,  1% 
ounces  lime-water,  which  mixture  gives  an  approximate  equivalent  of : 

0.33  per  cent.  fat. 

7.17  per  cent,  sugar. 

1.00  per  cent,  total  proteid. 

If  a  stronger  skimmed  milk  mixture  is  required,  it  may  be  prepared  as 
follows:  8  ounces  skimmed  milk,  8  ounces  water,  1  ounce  milk-sugar, 
which  mixture  gives  an  approximate  nutritional  equivalent  of: 

0.50  per  cent.  fat. 

7.75  per  cent,  sugar. 

1.50  per  cent,  total  proteid. 

It  will  thus  be  seen  that  with  milk,  cream,  and  sugar-of-milk,  food 
of  every  possible  strength  may  be  made.  If  Hme-water  is  used,  it 
simply  takes  the  place  of  the  milk  diluent  and  replaces  so  much  water. 
This  method  of  milk  preparation  is  more  accurate  than  when  top-milk 
mixtures  are  used,  but  it  has  the  disadvantage  of  requiring  two  quarts 
of  milk  during  the  entire  feeding  period,  one  to  supply  the  milk  and  the 
other  the  cream,  all  of  which  must  be  removed  and  mixed  before  any  of 
it  is  used  in  the  food. 

The  following  formulas  for  the  different  ages  may  be  found  useful 
for  well  babies : 

From  the  first  to  the  third  day: 

Milk-sugar J^^  ounce 

Boiled  water 16       ounces 

}i  to  1  ounce  every  two  or  three  hours 

which  mixture  gives  an  approximate  nutritional  equivalent  of  3  per 
cent,  sugar. 

From  the  third  to  the  tenth  day: 

Gravity  cream %   ounce  Approximate  Percentage  Equivalent 

Milk 43>^  ounces     Fat 1 .  25 

Milk-sugar 1 J^  ounces     Sugar 6 .  85 

Lime-water 1       ounce       Total  proteid 0 .  75 

Boiled  water  to  make 24       ounces 

Seven  feedings  in  twenty-four  hours;  2  to  3  ounces  at  each  feeding. 
One    ounce  =  12.8   calories. 

From  the  tenth  to  the  twenty-first  day: 

Gravity  cream 1^^   ounces  Approximate  Percentage  Equivalent 

Milk GJi  ounces     Fat 1.7 

Milk-sugar 2       ounces     Sugar 7.0 

Lime-water 2       ounces      Total  proteid 0 .  89 

Water  to  make 30       ounces 

Seven  feedings  in  twenty-four  hours;  3  to  4  ounces  at  each  feeding. 
One  ounce  =  14.4  calories. 


MODIFIED    MILK  59 

From  the  third  to  the  sixth  week: 

Gravity  cream 2J^   ounces  Approximate  Percentage  Equivalent 

Milk 8       ounces     Fat 2 .  25 

Milk-sugar 2       ounces     Sugar 7.25 

Lime-water 2       ounces     Total  proteid 1 .  13 

Water  to  make 32       ounces 

Seven  feedings  in  twenty-four  hours;  3  to  4  ounces  at  each  feeding. 
One  ounce  =  16.6  calories. 

From  the  sixth  week  to  the  third  month: 

Gravity  cream 3        ounces  Approximate  Percentage  Equivalent 

Milk 9       ounces     Fat 2.6 

Milk-sugar 2       ounces     Sugar 7.4 

Lime-water 2^-^  ounces     Total  proteid 1.3 

Water  to  make 32       ounces 

Seven  feedings  in  twenty-four  hours;  4  to  5  ounces  at  each  feeding. 
One    ounce  =  18   calories. 

From  the  third  to  the  fifth  month: 

Gravity  cream 4        ounces  Approximate  Percentage  Equivalent 

Milk 15       ounces     Fat 3.1 

Milk-sugar 2       ounces     Sugar 6.8 

Lime-water 3       ounces     Total  proteid 1.6 

Water  to  make 40       ounces 

Six  feedings  in  twenty-four  hours;  5  to  6  ounces  at  each  feeding. 

One  ounce  =  18.9  calories. 

From  the  fifth  to  the  seventh  month: 

Gravity  cream 6        ounces  Approximate  Percentage  Equivalent 

Milk 18       ounces     Fat 3.6 

Milk-sugar 2       ounces     Sugar 6.6 

Lime-water 3       ounces     Total  proteid 1.9 

Water  to  make 42       ounces 

Five  to  six  feedings  in  twenty-four  hours;  6  to  7  ounces  at  each  feeding. 
One  ounce  =  20.5  calories. 

After  the  fifth  month  it  is  my  custom  to  add  from  one  to  three  tea- 
spoonfuls  of  a  cereal  jelly  to  each  feeding.  This  may  be  added  to  the 
milk  mixture  when  it  is  made  in  the  morning.  Thus,  if  one  teaspoonful 
is  to  be  given  at  each  feeding,  where  a  child  is  getting  six  feedings,  six 
teaspoonfuls  of  the  jelly  may  be  added  to  the  entire  quantity. 

From  the  seventh  to  the  ninth  month: 

Gravity  cream 6        ounces  Approximate  Percentage  Equivalent 

Milk 23       ounces     Fat 3.9 

Milk-sugar 2       ounces     Sugar 6.5 

Lime-water 3       ounces     Total  proteid 2.1 

Water  to  make 48       ounces 

Five  feedings  in  twenty-four  hours;  7  to  8  ounces  at  each  feeding. 
One  ounce  =  21.4  calories. 

From  the  ninth  to  the  twelfth  month: 

Gravity  cream 7        ounces  Approximate  Percentage  Equivalent 

Milk 32       ounces     Fat 4.28 

Lime-water 4       ounces     Sugar 7 .  25 

Milk-sugar 2 J  i  ounces     Total  proteid 2.4 

Water  to  make 56       ounces 

Five  feedings  in  twenty-four  hours;   8  to   9  ounces  at  each  feeding. 
One  ounce  =  23.8  calories. 

Top-milk  Feeding. — In  using  top-milk  for  infant-feeding  the  milk 
is  allowed  to  stand  in  a  quart  bottle  at  a  temperature  of  45°  to  50°F. 


60  THE    PRACTICE    OF    PEDIATRICS 

five  hours.  The  quantity  needed  is  then  removed  from  the  top  of  the 
bottle  with  a  Chapin  dipper  (Fig.  4)  and  diluted  as  desired  with  water 
or  gruel  to  which  sugar-of-milk  and  lime-water  are  added.  The  milk 
selected  should  be  the  cleanest  obtainable  from  grade  cows;  usually 
the  most  expensive  is  the  best. 

From  a  quart  bottle  of  milk  on  which  the  cream  has  risen,  dip  from 
the  top  with  a  Chapin  dipper  16  ounces  and  mix.  From  average  milk 
this  should  contain: 


7.0  per  cent.  fat. 

3.2  per  cent,  sugar. 

3.2  per  cent,  total  proteid. 


The  following  top-milk  formulas  are  suggested  for  the  various  ages 
noted : 

From  the  third  to  the  tenth  day: 

Milk  (top  16  OZ.) 6        ounces  Approximate  Percentage  Equivalent 

Lime-water %  ounce       Fat 1 .  75 

Milk-sugar 1 J^  ounces     Sugar 6.6 

Boiled  water  to  make 24       ounces      Total  proteid 0.8 

Seven  feedings  in  twenty-four  hours;  2  to  3  ounces  at  each  feeding. 
One  ounce  =  12.5  calories. 

From  the  tenth  to  the  twenty- first  day: 

Milk  (top  16  OZ.) 7/-^   ounces  Approximate  Percentage  Equivalent 

Lime-water 2       ounces     Fat 1 .  75 

Milk-sugar 2       ounces     Sugar.  . 6.8 

Water  to  make 30       ounces      Total  proteid 0.8 

Seven  feedings  in  twenty-four  hours;  3  to  4  ounces  at  each  feeding. 
One  ounce  =  14.2  calories. 

From  the  third  to  the  sixth  week: 

Milk  (top  16  OZ.) 10       ounces  Approximate  Percentage  Equivalent 

Lime-water 2      ounces     Fat 2.2 

Milk-sugar 2       ounces     Sugar 7.0 

Water  to  make 32       ounces      Total  proteid 1.0 

Seven  feedings  in  twenty-four  hours;  3  to  4  ounces  at  each  feeding. 
One  ounce  =  16  calories. 

From  the  sixth  week  to  the  third  month: 

Milk  (top  16  OZ.) 12        ounces  Approximate  Percentage  Equivalent 

Milk-sugar 2       ounces     Fat 2.6 

Lime-water 2       ounces     Sugar 7.2 

Water  to  make 32       ounces      Total  proteid 1.2 

Seven  feedings  in  twenty-four  hours;  4  to  5  ounces  at  each  feeding. 
One  ounce  =  17.5  calories. 

From  the  third  to  the  fifth  month: 

After  this  age  two  bottles  of  milk  are  required,  16  ounces  being 
taken  from  the  top  of  each  bottle  and  mixed.  At  this  time  a  cereal 
jelly  is  usually  added  to  the  food. 

Milk  (top  16  OZ.) 18        ounces  Approximate  Percentage  Equivalent 

Milk-sugar 2       ounces     Fat 3.15 

Lime-water 3       ounces     Sugar 6.4 

Water  to  make 40       ounces     Total  proteid 1.4 

Six  feedings  in -twenty-four  hours;  5  to  6  ounces  at  each  feeding. 
One  ounce  =  18.3  calories. 


MODIFIED    MILK  61 

,  From  the  fifth  to  the  seventh  month: 

Milk|(top  16  OZ.) 21        ounces  Approximate  Percentage  Equivalent 

Milk-sugar 2       ounces     Fat • 3 .  50 

Lime-water 3       ounces     Sugar 6.4 

Water  to  make 42       ounces     Total  proteid 1.6 

Five  to  six  feedings  in  twenty-four  hours;  6  to  7  ounces  at  each  feeding. 
One  ounce  =  19.6  calories. 

From  the  seventh  to  the  ninth  month: 

Milk  (top  16  OZ.) 27        ounces  Approximate   Percentage  Equivalent 

Milk-sugar 2K  ounces     Fat 3.9 

Lime-water 3       ounces     Sugar 7.0 

Water  to  make 48       ounces     Total  proteid 1.8 

Five  feedings  in  twenty-four  hours;  7  to  8  ounces  at  each  feeding. 
One  ounce  =  21.7  calories. 

Frojn  the  ninth  to  the  twelfth  month: 

Milk  (top  16  OZ.) 35       ounces 

Milk-sugar 2}4  ounces     Fat 4.3 

Lime-water 4       ounces     Sugar 6.5 

Water  to  make 56       ounces     Total  proteid 2.0 

Five  feedings  in  twenty-four  hours;  8  to  9  ounces  at  each  feeding. 
One  ounce  =  22.4  calories. 

After  the  twelfth  month,  plain  cow's  milk  may  be  given  with  the  cereal 
jelly  in  addition  to  the  other  articles  of  diet  suggested  for  a  child  one 
year  old.     (See  p.  105.) 

Considerable  latitude  is  allowed  as  to  the  amount  of  food  which 
may  be  given  at  each  feeding,  because  of  the  difference  in  the  capacity 
of  individual  children.  It  will  be  observed  that  the  total  quantity  of 
food  prepared  may  be  a  few  ounces  more  than  the  amount  which  the 
child  will  ordinarily  take  in  twenty-four  hours.  This  extra  amount 
often  serves  a  most  useful  purpose  when  a  bottle  is  broken  or  the  food 
is  otherwise  lost.  The  average  well  child  will  require  daily  about  30 
ounces  of  a  suitably  adapted  food  at  the  third  month,  about  36  ounces 
at  the  sixth  month,  and  40  to  45  ounces  at  the  ninth  to  the  twelfth 
month. 

Night  Feedings. — After  the  third  month  the  midnight  feeding 
should  be  discontinued.  Six  feedings  are  sufficient,  the  first  at  6  a.  m. 
and  the  last  at  10  p.  m. 

Between  10  p.  m.  and  6  a.  m.  the  child  should  sleep.  Babies  are 
easily  weaned  from  the  night  bottle  by  substituting  a  bottle  of  boiled 
water  or  a  milk  mixture  greatly  diluted  with  water.  The  child  soon 
discovers  that  this  is  not  worth  waking  for.  As  a  result  of  a  fullnight's 
rest  the  digestive  organs  are  better  able  to  do  their  work,  the  appetite 
is  increased,  and.  a  larger  amount  of  food  may  be  given  at  each  feeding. 

The  Quality  of  Milk  Variable. — It  is  not  claimed  that  the  nutri- 
tional value  as  indicated  by  the  percentage  equivalents  in  either  of 
the  above  series  is  absolutely  correct.  Milks  necessarily  differ  in  com- 
position. Only  mixed  dairy  milk  is  referred  to,  the  product  of  several 
grade  cows.  The  feeding  of  the  cows  and  their  care  also  influence  the 
quality  of  the  milk.  The  percentages  given  indicate  approximately 
the  nutritional  value  and  are  sufficiently  accurate  for  purposes  of 


62  THE    PRACTICE    OF    PEDIATRICS 

supplying  satisfactory  nutrition  to  well  babies  of  the  various  ages,  as, 
I  have  abundantly  proved  to  my  own  satisfaction.  The  fat  will  not 
be  found  too  low  for  proper  nutrition  in  any  of  the  formulas  given.  It 
may  be  too  high  for  proper  digestion  and  require  adjustment.  The 
proteids  as  given  are  sufficient  for  nutrition  if  they  are  assimilated. 
They  also  may  require  reduction  to  meet  special  conditions  which  are 
referred  to  under  Milk  Adaptation  (p.  62).  The  adjustment  of  the 
food  to  the  individual  constitutes  what  I  have  termed  ''milk  adapta- 
tion," and  suggestions  for  making  the  food  fit  the  child's  digestive 
capacity  will  be  found  under  that  caption. 

Adapted  Milk. — In  adapting  milk  for  infant-feeding  the  milk  must 
not  only  be  "modified"  (p.  54),  by  which  process  the  nutritional  ele- 
ments are  changed  in  their  proportions  so  as  to  make  them  conform 
as  nearly  as  possible  to  mother's  milk,  but  more  is  required — the  food 
must  be  adapted  to  the  child's  digestive  capacity. 

If  the  modification  of  milk,  as  we  formerly  understood,  constituted 
all  that  was  required  in  infant-feeding,  the  artificial  feeding  of  infants 
would  be  a  comparatively  simple  matter.  Some  infants  will  take  read- 
ily any  reasonable  modification  which  by  experience  has  been  found 
suitable  for  children  of  their  age.  The  majority,  however,  who  are  fed 
on  cow's  milk,  must  be  fed  according  to  their  digestive  capabilities. 
Every  feeding  case  must  be  studied  from  the  individual  standpoint. 
How  best  to  nourish  the  individual  can  be  learned  only  by  a  study  of 
the  patient  himself.  No  process  of  manipulation  by  the  addition  of 
chemicals  or  gruels  can  convert  cow's  milk  into  human  milk.  Various 
means,  however,  are  available  sufficient  to  overcome  the  existing  dif- 
ferences, thereby  making  a  suitable  food  even  for  those  who  at  first 
show  signs  of  marked  intolerance  of  cow's  milk.  The  strength  of  the 
food  and  the  feeding  intervals  required  for  average  well  children  of  the 
different  ages  are  given  in  the  chapters  on  Modified  Milk,  p.  54. 

Symptomatic  Adaptation. — If  the  child  is  getting  a  food  of  suitable 
strength  at  proper  intervals  and  becomes  ill,  the  food  as  a  whole  may 
be  beyond  his  digestive  capacity,  or  there  may  be  an  incapacity  for 
one  or  more  nutritional  elements.  If  the  food  as  a  whole  is  too  strong, 
there  is  very  commonly  vomiting,  which  may  become  habitual,  or  there 
may  be  colic  or  constipation  or  diarrhea.  If  the  food  as  a  whole  is  too 
weak,  the  fact  will  be  evidenced  by  hunger,  failure  to  gain  in  weight, 
and  usually  by  constipation.  If  sugar  is  given  in  excess — a  compara- 
tively rare  cause  of  trouble,  if  not  more  than  7  per  cent,  of  milk-sugar 
is  given — it  will  be  indicated  by  the  regurgitation  of  sour,  watery 
material.  A  sour  odor  to  the  patient's  breath  and  clothing  indicates 
sugar  excess.  There  may  not  be  pronounced  vomiting  in  such  a  case, 
but  the  repeated  regurgitation  when  the  patient  is  awake  is  sufficient 
to  deprive  him  of  a  goodly  amount  of  his  daily  food.  The  digestion  of 
both  fat  and  proteid  may  be  markedly  interfered  with,  and  the  whole 
digestion  deranged  as  a  result  of  what  was  primarily  a  sugar  incapacity 
or  sugar  excess.  When  sugar  is  at  fault,  the  indigestion  may  readily 
be  corrected  by  washing  out  the  stomach  for  a  few  days  (p.  788)  and 


MODIFIED    MILK  63 

by  reducing  the  sugar  content  of  the  food  one-half.  Later,  after  the 
condition  is  reheved,  the  sugar  may  gradually  be  increased  to  the  nor- 
mal percentage  of  7.  A  child  may  be  getting  but  a  2  per  cent,  cow's- 
milk-fat  mixture  and  yet  suffer  from  fat-indigestion.  Excessive  fat  or 
fat  incapacity  also  gives  rise  to  vomiting  and  regurgitation  in  which 
particles  of  fat  may  often  be  seen.  Fat,  moreover,  may  cause  frequent 
green,  undigested  stools,  the  passage  of  which  is  associated  with  marked 
tenesmus.  Fat-diarrhea  is  often  the  outcome  of  fat-indigestion. 
Cow's-milk  fat  was  not  intended  for  babies,  and  when  it  disagrees — 
since  we  cannot  change  its  character — our  only  method  of  adaptation 
is  to  reduce  the  amount  given,  as  with  the  sugar. 

Casein. — The  casein  in  cow's  milk  is  its  important  nutritional 
constituent,  and  in  adapting  cow's  milk  to  a  child's  digestive  capacity 
the  casein  is  oftentimes  a  most  difficult  factor  to  deal  with.  Tempo- 
rarily it  may  be  reduced  with  safety  to  a  percentage  below  that  of  cow's 
milk — to  0.25  per  cent.,  for  instance — but  it  must  be  remembered  that 
the  patient  cannot  thrive  or  even  long  exist  without  this  proteid  ele- 
ment in  the  diet,  so  that  a  reduction  will  always  be  followed  by  malnu- 
trition. It  is  necessary,  then,  to  give  proteid,  and  successful  infant- 
feeding  means  that  we  must  adapt  the  proteid  to  the  child's  digestive 
capacity.     This,  fortunately,  is  oftentimes  possible. 

The  Use  of  Alkalis  and  Antacids. — The  casein  of  human  milk  when 
it  enters  the  infant's  stomach  separates  into  small,  fiocculent  masses. 
Cow's  milk  entering  the  infant's  stomach,  without  an  addition  of  an 
alkali  or  other  modifying  medium,  is  precipitated  by  the  pepsin  in  the 
stomach  and  forms  a  heavy  curd,  consisting  of  paracasein,  which  fails  of 
digestion  or  assimilation,  and  at  which  the  child's  stomach  oftentimes 
rebels.  The  adaptation  of  the  casein  of  cow^s  milk  to  the  child's  diges- 
tive capacity,  so  as  to  maintain  suitable  nutrition,  is  a  central  point  arouiid 
which  the  whole  subject  of  infant-feeding  revolves.  It  will  be  noted  in  the 
formulas  for  cow's-milk  feeding  for  different  ages  that  lime-water  is 
used  as  a  diluent.  This  is  used  not  simply  as  a  diluent  of  cow's  milk 
nor  to  render  the  milk  alkaline,  as  has  frequently  been  stated;  it  is 
used  to  prevent  the  coagulation  of  the  casein  and  the  resulting  forma- 
tion of  tough  curds  of  paracasein.  Simple  dilution  with  water  may 
make  a  smaller  curd,  but  does  not  produce  the  fiocculent  character 
peculiar  to  human  milk  that  follows  the  addition  of  alkalis  and  antacids 
to  cow's  milk.  In  the  presence  of  an  alkali  the  casein  does  not  com- 
bine with  the  acid  in  the  stomach;  consequently  the  resulting  acid 
coagulation  does  not  take  place.  For  this  reason  alkalis  and  antacids 
are  added  to  cow's  milk. 

Poynton,  of  London,  advocates  the  use  of  citrate  of  soda  with  a  view 
to  preventing  the  solid  coagulation  of  the  casein.  It  is  claimed  that  by 
using  citrate  of  soda,  1  grain  to  the  ounce,  sodium  paracasein  is  pro- 
duced, which  is  a  fluid.  Citric  acid  is  liberated  and  unites  with  the 
calcium,  forming  the  citrate  of  calcium,  which  is  absorbed. 

Signs  of  indigestion  of  the  casein  in  the  milk  are  usually  pain  and 
discomfort.     There  are  usually  acute  attacks  of  colic.     There  may  be 


64  THE    PRACTICE    OF    PEDIATRICS 

constipation,  or  diarrhea  alternating  with  constipation,  associated  with 
the  passage  of  many  hard  curds  in  the  stools,  the  patient  losing  steadily 
in  weight.  In  such  instances  the  best  means  of  adaptation  consists  in 
reducing  the  amount  of  proteid  to  a  total  of  1  per  cent,  by  dilution  with 
water,  and  the  addition  of  sufficient  antacids,  such  as  lime-water, 
bicarbonate  of  soda,  or  citrate  of  soda,  to  form  a  curd  more  readily 
attacked  by  the  digestive  juices.  The  writer  feeds  many  hundreds  of 
infants  yearly,  and  is  not  in  accord  with  the  belief,  which  is  now  fashion- 
able, that  the  casein  of  cow 's  milk  is  a  factor  of  no  im'portance  in  the  adap- 
tation  of  cow 's  milk. 

Whey-feeding. — Whey  mixtures  may  be  of  temporary  use  in  these 
cases.  In  whey  the  casein  is  largely  removed — about  0.3  per  cent, 
remaining.     Analyses  of  whey  show  a  nutritional  equivalent  of  about: 


0.5  per  cent.  fat. 
0.9  per  cent,  lactalbumin. 
0.3  per  cent,  casein. 
4.5  per  cent,  sugar. 


As  whey  is  ordinarily  made,  it  is  impossible  to  obtain  a  lower  percentage 
of  casein  than  0.25.  The  amount  of  casein  will  oftentimes  reach  0.5 
per  cent,  unless  it  is  heated  and  strained  a  second  time.  The  deficiency 
in  fat  may  be  overcome  by  adding  gra.vity  cream  (p.  73)  of  the  same 
age  as  the  milk  from  which  the  whey  is  obtained,  in  the  proportion  of 
one  or  two  ounces  to  a  pint  of  whey.  This,  of  course,  carries  with  it  a 
very  small  amount  of  casein,  which  may  make  a  total  beyond  the 
child's  digestive  capacity.  Low  proteid  must  be  given  only  during 
acute  illness  or  indigestion,  and  should  be  a  diet  for  temporary  purposes 
until  the  child  is  able  to  care  for  more  suitable  nourishment. 

Adaptation  by  the  Use  of  Cereal  Gruels. — Cereals  may  be  added  to 
milk  with  advantage  from  two  standpoints :  they  increase  the  nutritive 
value  of  the  food  mixture  and  when  cooked  with  milk  add  very  mate- 
rially to  the  digestibility  of  the  milk,  particularly  if  an  antacid  like 
carbonate  of  soda  or  citrate  of  soda  is  added  in  small  amounts — 5 
grains  to  the  day's  allowance.  That  the  cooking  of  milk  with  starch 
is  of  distinct  value  has  been  abundantly  proven  in  the  use  of  malt 
soup. 

Malt-soup  Feeding. — The  use  of  Loeffiund's  nialt-soup  extract 
(a  preparation  of  malt  and  potassium  carbonate),  Keller's  formula, 
offers  a  most  satisfactory  method  of  making  cow's  milk  assimilable. 
It  is  not  well  borne  in  vomiting  cases  nor  those  in  which  there  is  a 
tendency  to  looseness  of  the  bowels.  When  either  of  these  conditions 
exists  skimmed  milk  may  be  temporarily  substituted. 

In  following  this  method  of  feeding,  the  milk  strength  considered 
suitable  for  the  condition  and  age  of  the  child  may  be  used.  Lime- 
water  is  not  employed  because  of  the  presence  of  carbonate  of  potash 
in  the  malt.  The  malt  and  the  flour,  a  considerable  portion  of  the 
latter  having  been  dextrinized,  take  the  place  of  milk  sugar  or  cane- 
sugar  in  the  food  mixture. 


MODIFIED    MILK  65 

The  chief  use  of  this  food  is  in  malnutrition  cases,  in  slow-growing 
infants,  who  though  not  actually  ill,  fail  to  show  a  satisfactory  growth 
on  any  other  food  given.  Time  and  again  I  have  seen  these  children 
show  surprising  increase  in  weight  without  change  in  the  milk  strength 
when  the  malt-soup  with  its  flour  accompaniment  was  used.  In 
treating  bottle-fed  infants  who  suffer  from  colic  and  marked  con- 
stipation this  food  has  a  considerable  field  of  usefulness. 

Malt-soup  extract  is  not  to  be  used  in  the  strength  indicated  on 
the  bottle,  as  the  amount  is  entirely  too  high.  I  have  found  the 
following  method  the  most  satisfactory:  For  a  30-ounce  mixture, 
dissolve  1  ounce  of  the  malt  extract  in  the  amount  of  water  used.  Mix 
and  blend  from  1  to  2  ounces  (by  measure)  of  Robinson's  Barley  Flour 
or  Imperial  Granum  with  the  milk,  cream,  or  top-milk  required.  If 
there  is  abdominal  distention  and  flatulence  or  other  evidence  of 
carbohydrate  incapacity,  the  amount  of  flour  should  be  reduced  per- 
haps one-half.  The  milk  and  flour  mixture  is  to  be  strained  and  added 
to  the  solution  of  malt  and  water.  It  should  then  be  placed  over  a 
slow  fire  and  "simmered"  for  thirty  minutes,  with  constant  stirring. 

Instead  of  using  wheat  flour  as  directed  on  the  package  of  malt 
soup,  I  have  for  some  time  been  using  Robinson's  Barley  Flour  (baked 
barley  flour)  or  Imperial  Granum  (baked  wheat  flour)  with  better 
results  in  many  difficult  cases  than  when  raw  wheat  flour  was  used. 

In  the  event  of  constipation  continuing,  the  amount  of  malt  used 
may  be  doubled.  Excess  of  malt,  however,  may  produce  vomiting, 
so  that  any  increase  should  be  made  with  caution. 

Eiweiss  Milch  (Protein  Milk). — The  Eiweiss  Milch  of  Finkelstein 
and  Meyer  is  prepared  as  follows: 

To  one  quart  of  milk  heated  to  100°F.  add  one  junket  tablet  dis- 
solved in  water,  and  stir  for  a  few  seconds.  Stand  at  room  tempera- 
ture until  firmly  coagulated:  strain  through  gauze  and  wash  curd 
twice  with  cold  boiled  water.  Rub  dry  curd  through  fine  wire  sieve, 
gradually  adding  one  pint  of  lactic-acid  milk.  Enough  boiled  water 
is  then  added  to  make  one  quart. 

Lactic  Acid  Milk. — ^Lactic  acid  milk  is  prepared  as  follows: 

One  Lactone  Tablet  (Parke,  Davis  &  Co.)  is  added  to  one  quart 
skimmed  milk,  and  allowed  to  stand  at  98°F.  for  twenty-four  hours. 

Eiweiss  Milch  (Protein  Milk)  is  a  most  satisfactory  diet  for  infants 
acutely  ill  with  diarrheal  disturbances.  (One  grain  of  saccharine  may 
be  added  to  each  pint  to  make  it  more  palatable.)  It  may  be  given 
with  advantage  when  plain  cow's  milk  is  dangerous.  It  may  be  used 
at  all  ages.  It  is  well  taken  by  most  infants  after  a  few  trials;  It  is 
usually  well  retained.  The  stools  improve  rapidly  under  its  use,  be- 
coming yellow  and  smooth.  It  constitutes  a  means  of  nutrition,  which 
may  be  brought  into  use  much  earlier  than  plain  modified  cow's  milk, 
thus  taking  the  place  of  the  cereal  decoctions. 

Our  plan  in  a  given  case  of  acute  intestinal  intoxication  is  as  follows : 
Two  teaspoonfuls  of  castor  oil  are  given.  This  is  followed  by  plain 
barley-water,  one  ounce  to  the  pint,  for  twenty-four  hours.  At  the 
5 


66  THE    PRACTICE    OF    PEDIATRICS 

end  of  this  time,  regardless  of  the  character  of  the  stools,  the  Eiweiss 
Milch  is  introduced.  Aside  from  what  action  the  protein  milk  may- 
possess  as  a  remedial  agent,  it  furnishes  a  food  that  may  be  given  with 
safety  in  all  cases  during  a  very  trying  period.  I  usually  begin  with 
equal  parts  of  Eiweiss  Milch  and  barley-water  and  later  increase  the 
milk  strength  about  25  per  cent. 

Children  kept  on  the  Eiweiss  Milch  for  a  considerable  period  rarely 
continue  to  do  well,  so  that  cow's  milk  is  to  be  resumed  as  soon  as  it  is 
thought  safe,  perhaps  after  a  week  or  two. 

The  Calorimetric  Standard. — The  calorimetric  standard  is  based 
upon  the  amount  of  energy  indicated  in  calories  for  each  pound  of  body 
weight.  A  calorie  is  the  amount  of  heat  required  to  raise  the  tempera- 
ture of  one  liter  of  water  1°C. 

Heubner,  of  Berlin,  several  years  ago  began  the  employment  of  cal- 
orimetric principles  in  infant-feeding.  His  original  observations, 
which  were  made  on  healthy  breast-fed  infants,  weighed  before  and  after 
each  feeding,  showed  that  under  six  months  100  calories  were  required 
daily  for  every  kilogram  of  body  weight.  After  the  sixth  month,  the 
number  of  calories  required  gradually  lessened,  so  that  at  the  comple- 
tion of  one  year  about  85  calories  to  each  kilogram  of  body  weight 
appeared  to  be  necessary. 

Lamb  has  reduced  Heubner 's  figures  to  pounds.  He  gives  the 
calorimetric  requirements  during  the  first  three  months  of  life  as  45 
calories  daily  per  pound  of  body  weight,  during  the  next  three  months 
from  40  to  45  calories  daily  per  pound,  decreasing  gradually  during  the 
next  six  months,  so  that  at  the  twelfth  month  from  32  to  35  calories 
daily  per  pound  of  body  weight  are  necessary. 

The  following  table  represents  the  caloric  values  of  foods  ordi- 
narily employed  in  infant  feeding. 

CALORIC  VALUES 

1  ounce  7  per  cent,  milk 27.5 

1  ounce  4  per  cent,  milk 20 

1  ounce  Fat  Free  Milk 10 

1  ounce  Breast  Milk 20 

1  ounce  Barley  Flour 100 

1  ounce  Barley  Water  (1  tablespoon  to  1  pint) 2.0 

1  ounce  Oat  Flour 110 

1  ounce  Imperial  Granum 100 

1  ounce  Milk  Sugar . .  .  .• 116 

1  ounce  Dextro- Maltose 100 

1  ounce  Malt  Soup 80 

1  ounce  Sweetened  Condensed  Milk 132 

1  ounce  Unsweetened  Condensed  Milk 42 

CEREAL  GRUELS;  STARCH-FEEDING 

Much  discussion  has  taken  place  concerning  the  use  of  cereals  in 
infant-feeding. 

The  cereals  consist  of  plant  embryos  surrounded  by  a  mass  of  highly 
nutritious  proteids  and  carbohydrates  in  the  form  of  starch,  which 
nourish  the  embryonic  plant  until  it  becomes  rooted  in  the  ground. 


CEREAL    gruels;    STARCH-FEEDING  67 

As  the  developing  plant  needs  nourishment  it  converts  the  starch  into 
dextrin  and  maltose.  Cereals  are  analogous  to  eggs  in  that  the  germ 
is  packed  away  in  a  supply  of  exceedingly  nutritious  food,  which  in  the 
process  of  development  it  converts  into  tissue.  Almost  all  of  the  pre- 
pared infant  foods  are  made  from  cereal  flours,  with  or  without  the 
addition  of  a  little  dried  milk  or  sugar;  or  from  cereals  in  which  the 
starch  has  been  transformed  into  dextrin  and  maltose.  The  proprie- 
tary meal  foods,  which  consist  of  baked  flours  of  different  kinds,  are 
useful  aids  in  infant-feeding  and  most  useful  as  milk  substitutes  when 
milk  must  temporarily  be  withheld.  The  conversion  of  starch  into 
dextrin  by  the  baking  process  is  so  slight  that  it  may  be  ignored. 
Robinson's  barley  flour,  Cereo  Co.'s  barley  flour  and  the  other  gruel 
flours,  and  Imperial  Granum  (baked  wheat  flour)  require  boiling  before 
use.  They  may  be  prepared  according  to  the  instructions  given  in 
the  formulary  (p.  71). 

It  is  my  custom  in  bottle-feeding  to  begin  with  a  cereal  from  the 
fifth  to  the  seventh  month,  by  using  a  cereal  water  as  a  diluent  of  the 
milk  mixture.  For  this  purpose  barley  or  granum  is  usually  employed. 
Very  often  in  out-patient  work  I  begin  with  a  cereal  diluent  very  early 
in  life  in  order  to  make  the  food  mixture  more  nutritious.  This  method  of 
feeding  is  useful  when  accurate  modifications  are  not  possible  and  when 
the  child  for  any  reason  cannot  take  a  milk  formula  as  strong  as  age 
and  nutritional  requirements  demand.  Such  cases  are  frequently 
seen  in  the  marasmic,  the  malnutrition,  and  the  difficult  feeding  class. 
The  addition  of  two  or  three  tablespoonfuls  of  flour  to  the  daily  food 
will  increase  its  nutritive  value  not  a  little.  That  boiled  starch  may  be 
digested  by  the  youngest  and  most  marasmic  infant  has  been  proved 
under  my  own  observation. 

The  principal  use  of  these  flours,  however,  is  in -the  treatment  of 
gastro-enteric  diseases,  where  cereal  may  with  safety  replace  the  milk 
for  considerable  periods  of  time.  By  eliminating  milk  from  the  diet 
and  giving  carbohydrates,  a  putrefactive  culture-fleld  is  removed  and 
a  less  favorable  soil  is  furnished  for  the  development  of  the  intestinal 
bacteria;  further,  there  are  no  by-products  formed  to  produce  intestinal 
toxemia  or  kidney  irritation.  Two  even  tablespoonfuls  of  these  flours 
to  one  pint  of  water  give  approximately  a  food  strength  of  0.07  per 
cent,  fat,  0.3  per  cent,  proteid,  2  per  cent,  carbohydrate.  In  order 
to  increase  the  nutritive  value,  cane-sugar  may  be  added  in  sufficient 
quantity  to  bring  the  carbohydrate  percentage  up  to  5.  The  addition 
of  the  sugar  also  makes  the  cereal  more  palatable,  and  therefore  more 
acceptable  to  the  patient. 

During  an  invasion  of  scarlet  fever,  pneumonia,  or  any  of  the  ill- 
nesses of  childhood  which  may  be  accompanied  by  great  prostration, 
the  usual  foods,  whatever  their  nature,  should  be  withheld,  and  the 
cereal  gruel  alone  or  mixed  with  chicken  or  mutton  broth  used  as  a  very 
satisfactory  substitute.  Likewise  later  in  the  disease  it  is  never  well 
to  give  full  milk  while  fever  and  prostration  are  present.  Cereal  gruels 
are  especially  serviceable  as  diluents  of  the  milk  in  conditions  where 


68  THE    PKACTICE    OF    PEDIATRICS 

this  combination  must  often  furnish  the  nutrition  for  days.  The  use 
of  the  baked-flour  gruels,  with  sugar  or  without,  as  a  means  of  nutri- 
tion should  be  continued  only  during  the  active  symptoms  of  the  disease, 
whether  it  is  scarlet  fever  or  one  of  the  intestinal  diseases.  In  no  sense 
are  these  gruels  advocated  as  exclusive  foods  for  infants  or  for  growing 
children.  .  I  have  seen  many  cases  in  which  this  error  has  been  made 
with  most  disastrous  results. 

The  Infant's  Capacity  for  Starch  Digestion  Proved  hy  Experiment. — ■ 
It  has  been  claimed  with^nore  or  less  tenacity  by  different  writers  that 
the  young  infant  possesses  no  capacity  for  starch  digestion.  That 
the  youngest  infants  may  digest  starch  is  now  definitely  established. 
The  experiments  of  Moro,  Zwiefel,  Corwin,  Hess*  and  the  Author! 
have  proven  the  earlier  beliefs  erroneous. 

PEPTONIZED  MILK 

Milk  is  peptonized,  or  predigested,  for  the  purpose  of  partially  or 
completely  digesting  the  proteid  before  it  is  given  to  the  patient.  As 
a  means  of  assistance  in  making  a  milk  food  assimilable  the  usefulness 
of  peptonization  is  limited.  So-called  complete  peptonization  pro- 
duces a  product  with  a  decidedly  bitter  taste,  which  few  children  will 
take.  Peptonized  milk,  however,  has  other  uses  than  as  a  means  of 
daily  feeding.  Peptonized  milk  in  which  there  is  a  complete  conversion 
of  the  casein  has  been  most  useful  in  two  types  of  cases : 

For  Gavage. — During  acute  or  chronic  illness  when  a  child  cannot 
take  food  by  the  natural  method,  as  in  diphtheric  paralysis,  or  when 
he  will  not  swallow  on  account  of  an  acute  inflammatory  disease  of  the 
throat,  such  as  peritonsillitis,  retropharyngeal  abscess,  or  retropharyn- 
geal adenitis,  or  when  he  is  in  a  comatose  condition  from  any  cause 
except  intestinal  infection,  the  feeding  of  completely  peptonized  milk 
by  gavage  (p.  790)  is  of  inestimable  value. 

For  Nutrient  Enema. — In  conditions  when  stomach-feeding  is  im- 
possible either  by  gavage  or  the  natural  method — conditions  met  with 
in  persistent  vomiting  due  to  acute  cerebral  diseases,  in  recurrent  vomit- 
ing, in  acute  gastric  indigestion — and  as  an  accessory  means  of  feeding 
when  sufficient  nourishment  cannot  be  taken  by  the  stomach,  the  colon- 
feeding  of  completely  peptonized,  skimmed  milk  has  a  decided  field  of 
usefulness,  and  in  this  way  I  often  employ  it.  Feeding  children  by 
means  of  the  bowel,  however,  is  usually  possible  for  a  few  days  only,  be- 
cause of  the  local  irritation  produced  by  the  nutriment  and  by  the  pas- 
sage of  the  tube.  Skimmed  milk,  peptonized,  with  the  addition  of 
the  white  of  egg  makes  the  best  nutrient  enema  that  I  have  used. 
It  should  be  given  at  a  temperature  between  90°  and  95°F,  at  from  six- 
to  eight-hour  intervals.  The  tube  should  be  introduced  at  least  9 
inches.  In  cases  of  recurrent  vomiting  I  have  repeatedly  seen  both 
hunger  and  thirst  relieved  by  feeding  in  this  way.  The  following  are 
the  different  methods  for  the  peptonization  of  milk: 

*  American  Journal  Diseases  of  Children. 
t  Kerley,  Mason  and  Cray. 


MILK    FOR    TRAVELING  69 

Peptonization. — Immediate  Process. — Fifteen  minutes  before  feed- 
ing add  from  }'g  to  3^^  of  the  contents  of  a  Fairchild  peptonizing  tube  to 
the  milk  mixture  which  is  in  the  nursing-bottle  ready  for  use.  Place 
the  bottle  in  water  at  a  temperature  of  from  110°  to  120°F.,  and  let  it 
remain  for  fifteen  minutes.  The  amount  of  the  powder  used  and  the 
degree  of  heat  of  the  water  depend,  of  course,  upon  the  amount  of 
milk  in  the  nursing-bottle. 

Cold  Process. — Put  4  ounces  of  cold  water  into  a  clean  quart  bottle 
and  dissolve  in  it,  by  shaking  thoroughly,  the  powder  contained  in  one 
of  the  Fairchild  peptonizing  tubes;  add  a  pint  of  cold  fresh  milk,  shake 
the  bottle  again,  and  immediately  place  it  upon  ice — directly  in  con- 
tact with  it. 

The  bottle  should  always  be  well  shaken  before  and  after  pouring 
out  a  portion  of  its  contents. 

Partially  Peptonized  Milk. — Put  4  ounces  of  cold  water  and  the 
powder  contained  in  one  of  the  Fairchild  peptonizing  tubes  into  a  clean 
saucepan,  and  stir  well;  add  a  pint  of  cold  fresh  milk  and  heat  to 
the  boiling-point,  stirring  constantly.  The  heat  should  be  so  applied 
that  the  milk  will  come  to  a  boil  in  ten  minutes.  Let  it  cool  until  luke- 
warm, then  strain  into  a  clean  bottle  or  glass  jar,  cork  tightly  and  keep 
in  a  cold  place.  The  bottle  or  jar  should  always  be  well  shaken  before 
and  after  pouring  out  a  portion. 

Partially  peptonized  milk,  if  properly  prepared,  will  not  become 
bitter. 

Completely  Peptonized  Milk. — Put  4  ounces  of  cold  water  and  the 
powder  contained  in  one  of  the  Fairchild  peptonizing  tubes  into  a 
clean  quart  bottle  and  shake  thoroughly;  add  a  pint  of  cold  fresh  milk 
and  shake  again ;  then  place  the  bottle  in  a  pail  or  kettle  of  warm  water 
at  about  115°F.,  or  not  too  hot  to  immerse  the  hand  in  it  without  dis- 
comfort. Keep  the  bottle  in  the  water-bath  for  thirty  minutes.  Put 
it  immediately  upon  ice — directly  in  contact  with  it. 

MILK  FOR  TRAVELING 

In  making  long  journeys  with  infants  by  land  or  water,  the  feeding 
of  the  child  is  an  important  matter,  and  advice  is  often  sought  by  moth- 
ers who  wish  to  make  the  contemplated  trip  with  the  least  possible 
risk.  It  is,  of  course,  desirable  that  no  change  be  made  in  the  milk 
commonly  used,  and  there  are  means  of  treating  the  milk  and  of  keep- 
ing it  which  enable  us  to  assure  the  patient  of  reasonable  safety.  It 
is  my  custom  with  city  children  to  have  the  milk  prepared  at  the 
Walker-Gordon  Laboratory,  where  at  a  trifling  expense  small  ice-boxes 
can  be  obtained  which  contain  sufficient  space  for  a  few  days'  supply  of 
milk  and  which  can  be  conveniently  carried  on  cars  and  boats.  Larger 
boxes  with  a  capacity  of  12  quarts  may  be  used  for  an  ocean  voyage. 
The  smaller  box  will  need  refilling  with  ice,  which  is  usually  readily 
secured  once  or  twice  a  day.  The  larger  box  for  ocean  voyages  is 
packed  in  ice  and  placed  in  a  cold-storage  room  of  the  vessel  and  will 
not  need  repacking  during  the  trip.     The  milk  prepared  for  a  journey 


70  THE    PRACTICE    OF    PEDIATRICS 

should  be  cooled  to  45°F.  as  soon  as  it  is  drawn,  and  kept  at  this  tem- 
perature until  it  can  be  sterilized  at  a  temperature  of  212°F.  for  twenty 
minutes.  It  should  then  be  cooled  rapidly  to  at  least  50°F.  and  kept 
at  this  point  until  used.  These  directions  can  be  carried  out  by  any 
intelligent  family.  When  this  is  done,  the  milk  will  be  safe  for  use  for 
the  time  required — from  seven  to  eight  days.  Of  course,  laboratory 
milk  is  available  for  comparatively  few.  But  the  suggestion  as  to  the 
making  of  an  ice-box  can  be  followed  in  any  town  or  village,  so  that  a 
milk  laboratory  is  not  essential.  All  that  is  required  is  the  ice-box,  ice, 
the  quart  fruit-jars  or  quart  milk-bottles,  and  clean  milk.  Those  who 
for  any  reason  cannot  avail  themselves,  of  the  milk  thus  preserved 
will  find  in  canned  condensed  milk  a  fairly  good  substitute.  See 
Condensed  Milk  (p.  95). 

FOOD  FORMULAS 

Beef-juice. — Take  a  round  steak,  cut  into  pieces  the  size  of  a  horse- 
chestnut,  place  in  a  buttered  pan  in  a  hot  oven,  and  bake  for  fifteen 
minutes;  remove  from  the  pan  and  press  out  the  blood;  add  salt  to  the 
taste. 

Beef,  Mutton,  and  Chicken  Broth. — Take  one  pound  of  meat  free 
from  fat,  cook  for  three  hours  in  one  quart  of  water,  adding  water  from 
time  to  time,  so  that  when  the  cooking  is  completed  there  will  be  one 
quart  of  broth.  When  the  broth  is  cool,  remove  the  fat,  strain,  and 
add  salt  to  the  taste. 

Scraped  Beef.— Broil  round  steak  slightly  over  a  brisk  fire.  Split 
the  steak  and  scrape  out  the  pulp,  using  a  dull  knife. 

Egg-water. — The  white  of  one  egg,  thoroughly  beaten  in  one  pint 
of  cold  boiled  water;  strain;  add  salt  to  the  taste. 

Oatmeal  Jelly. — Oatmeal,  four  ounces;  water,  one  pint;  boil  for 
three  hours  in  a  double  boiler,  water  being  added,  so  that  when  the 
cooking  is  completed  a  thin  paste  will  be  formed.  This  while  hot  is 
forced  through  a  colander  to  remove  the  coarser  particles.  When  cold, 
a  semi-solid  mass  will  be  formed. 

Wheat  Jelly  and  Barley  Jelly. — Wheat  jelly  and  barley  jelly  are 
made  in  the  same  way  as  oatmeal  jelly,  using  cracked  wheat  or  barley 
grains. 

Barley-water  No.  i. — Robinson's  barley  flour  or  Cereo  Co.'s 
barley  flour,  one  rounded  tablespoonf ul ;  water,  one  pint.  Boil 
thirty  minutes;  strain;  add  water  to  make  one  pint. 

In  making  barley-water  No.  2  two  tablespoonfuls  of  the  flour  are 
used,  and  for  No.  3  three  tablespoonfuls  are  used. 

Imperial  Granum  is  used  in  strengths  identical  with  barley. 

Rice-water  No.  i. — Rice,  one  tablespoonf  ul ;  water,  one  pint;  boil 
three  hours,  adding  water  from  time  to  time,  so  that  there  is  one  pint  of 
rice-water  at  the  end  of  the  three  hours. 

In  making  rice-water  No.  2  two  tablespoonfuls  of  rice  are  used. 

Percentage  Gruel  Flours. — There  has  recently  been  put  on  the 
market  in  tin  boxes,  the  covers  of  which  are  used  as  measures,  a  series 


THE    PROPRIETARY   FOODS 


71 


of  flours,  especially  made  for  preparing  cereal  gruels  and  jellies  of  known 
percentage  composition.  On  the  labels  are  given  only  the  cooking 
directions  for  preparing  plain  or  dextrinized  gruels,  and  their  com- 
position when  different  quantities  of  flour  are  used.  They  are  as 
follows : 

APPROXIMATE  COMPOSITION  OF  GRUELS  MADE  FROM  GEREO  GO.'S 

GRUEL  FLOURS 


Barley 

Legume* 

Oat 

Wheat 

4i 
Is 

PL,  n 

4i 

O  u 
I.  <u 
Ph  ft 

■£2S 

•a  fl 
P^  ft 

Carbo- 
hydrates, 
per  cent. 

■  s  g 

O  t. 

Ph  ft 

o  "  =1 
^ja  ft 

0.12 

0.60 

0.19 

0.53 

0.12 

0.60 

0.10 

0.62 

0.24 

1.20 

0.39 

1.06 

0.24 

1.20 

0.20 

1.25 

0.36 

1.80 

0.58 

1.59 

0.36 

1.80 

0.30 

1.88 

0.48 

2.40 

0.78 

2.12 

0.48 

2.40 

0.40 

2.50 

0.96 

4.80 

1.56 

4.24 

0.96 

4.80 

0.80 

5.00 

1.44 

7.20 

2.34 

6.36 

1.44 

7.20 

1.20 

7.50 

1.99 

9.60 

3.12 

8.40 

1.92 

9.60 

1.60 

10.00 

34  ounce  flour  to  quart  of 
■water 

^i  ounce  flour  to  quart  of 
water 

%  ounce  flour  to  quart  of 
water 

1  ounce  flour  to  quart  of 
water 

2  ounces  flour  to  quart  of 
water 

3  ounces  flour  to  quart  of 
water 

4  ounces  flour  to  quart  of 
water 


*  Made  from  equal  parts  of  peas,  beans,  and  lentils. 

Dextrinized  Barley-water. — Robinson's  barley  flour  or  Cereo  Co.'s 
barley  flour,  three  tablespoonfuls ;  water,  one  pint;  boil  thirty  min- 
utes; add  water  to  make  a  pint.  When  lukewarm  (100°F.),  add  one 
teaspoonful  of  Cereo;  strain;  this  changes  the  starch  into  dextrinized 
maltose. 

Oatmeal-water  No.  i. — Oatmeal,  one  tablespoonf ul ;  water,  one 
pint ;  cook  three  hours  and  add  water  to  make  one  pint. 

In  making  oatmeal-water  No.  2  two  tablespoonfuls  of  oatmeal  are 
used. 

"Whey. — Put  one  pint  of  fresh  milk  into  a  saucepan  and  heat  it  luke- 
warm— not  over  100°F.;  then  add  two  teaspoonfuls  of  Fairchild's 
essence  of  pepsin  and  stir  just  enough  to  mix.  Let  it  stand  until  flrmly 
jellied,  then  beat  with  a  fork  until  it  is  finely  divided;  strain,  and  the 
whey,  the  liquid  part,  is  ready  for  use. 

Junket. — To  one  quart  of  milk  heated  to  100°F.  add  one  table- 
poon  sugar,  one  junket  tablet  or  half  an  ounce  liquid  rennet,  and  few 
drops  of  vanilla.  Stand  at  room  temperature  until  firmly  coagulated, 
then  place    on  ice. 

THE  PROPRIETARY  FOODS 

The  foods  on  the  market  prepared  for  purposes  of  infant-feeding  are 
very  numerous.     From  our  knowledge  of  the  composition  of  mother 's 


72  THE    PEACTICE    OF    PEDIATRICS 

milk  we  learn  what  nutritional  elements  are  required,  and  approxi- 
mately in  what  relative  proportions  these  elements  must  exist,  in  order 
to  supply  the  child  with  the  food  which  nature  intended  him  to  have. 
The  examination  of  the  milk  of  thousands  of  nursing  women  shows  that 
it  contains  from  2.5  to  4  per  cent,  fat,  6  to  7  per  cent,  sugar,  and  1  to 
1.5  per  cent,  proteid;  and  this  furnishes  the  balanced  ration  with  nor- 
mal caloric  requirements.  These  figures  may  be  put  down  as  the 
normal  limits  of  human  milk,  and  they  are  so,  simply  because  the 
infant  will  thrive  and  grow  when  the  nutritional  elements  in  approxi- 
mately the  above  proportions  are  supplied  to  him.  It  is  within  these 
limits  that  the  food  must  be  kept  in  order  that  there  may  be  normal 
growth  and  development;  though,  of  course,  wide  variations  from  these 
may  be  of  temporary  occurrence.  While  the  child  may  exist  and 
temporarily  do  fairly  well  on  a  percentage  of  fat  lower  than  2.5,  he  will 
invariably  show  defective  growth  if  the  proteid  remains  persistently 
under  1  per  cent.  The  chief  disadvantage  in  the  infant  foods  which  are 
used  without  the  addition  of  cow's  milk,  lies  in  the  fact  that  they  do 
not  contain  the  nutritional  elements  as  they  exist  in  normal  breast-milk, 
and  besides,  of  necessity,  they  are  all  cooked  foods. 

In  selecting  a  substitute  for  mother 's  milk  (p.  48)  one  point  is  to  be 
kept  in  mind,  viz.,  the  substitute  should  contain,  in  a  readily  assimilable 
form,  the  nutritional  elements  in  approximately  the  proportions  and 
forms  in  which  they  exist  in  mother's  milk.  All  other  feeding  is  de- 
fective. It  is  not  well  to  put  too  much  reliance  on  the  analysis  some- 
times published  by  the  proprietary  food  manufacturer.  This  type  of 
food  is  decidedly  weak  in  animal  fat  for  the  reason  that  there  is  no 
means  of  keeping  more  than  a  small  percentage  of  it  in  a  food  without 
its  becoming  rancid.  When  considerable  percentages  are  indicated  in 
the  analysis,  it  is  certain  that  the  fat  does  not  consist  of  butter-fat. 
The  quantity  of  animal  milk  proteid  is  likewise  deficient,  and  what  is 
present  has  been  cooked,  which  detracts  materially  from  the  value 
of  the  food  in  infant  nutrition.  Scurvy  is  not  an  infrequent  result 
of  the  exclusive  use  of  these  foods. 

The  Uses  of  Proprietary  Dried-milk  Foods. — It  is  to  be  remembered 
that  this  type  of  food  is  condemned  because  of  its  being  an  unsuitable 
food  when  used  exclusively  and  persistently.  Hysteric,  general  con- 
demnation of  the  proprietary  infant  foods  is  unjust.  Throughout  this 
book  the  uses  of  the  proprietary  foods  will  be  mentioned  from  time  to 
time  and  dwelt  upon.  Milk  is  often  an  important  factor  in  the  pro- 
duction of  constipation;  and  the  importance  of  this  food  in  the  nutrition 
of  "runabout"  and  the  older  children  who  are  on  a  general  diet  is  sec- 
ondary. In  such  cases  cow's  milk  may  be  replaced  by  one  of  the  pro- 
prietary dried-milk,  malted  foods  which  has  a  laxative  effect.  I  some- 
times employ  them  in  other  disordered  states.  During  acute  illness 
and  in  convalescence  from  illness  and  in  certain  forms  of  malnutrition 
such  foods  are  usually  readily  digested  and  may  help  us  over  difficult 
places. 


CREAM  73 

Proprietary  Foods  to  Which  Fresh  Cow's  Milk  is  Added. — These 
are  not  foods  in  the  usual  acceptation  of  the  term,  and  if  they  are  used 
alone,  independent  of  milk,  the  patient  will  soon  present  a  sorry  spec- 
tacle. They  are  largely  sugars,  being  composed  of  maltose  and  dex- 
trose, which  are  derived  from  starch.  Some  contain  a  considerable 
quantity  of  unconverted  starch.  When  added  to  the  water  and  milk 
mixtures  they  furnish  the  soluble  carbohydrates  and  free  starch, 
and  thus  fulfil  this  function  of  the  food  with  results  as  good  as,  but 
usually  no  better  than,  those  obtained  with  milk-sugar  and  a  cereal 
gruel.  Maltose  is  a  laxative  sugar.  In  some  cases  of  constipation 
in  the  bottle-fed  it  may  replace  the  milk-sugar  in  equal  quantity,  with 
decided  advantage.  In  other  cases  this  change  to  maltose  is  without 
effect. 

According  to  my  observation,  the  statement  that  the  addition  of 
maltose  to  cow's  milk  facilitates  its  digestion  is  unfounded.  I  have 
tried  this  method  in  many  cases,  but  have  never  been  able  in  conse- 
quence to  use  a  stronger  cow  's-milk  mixture.  The  true  test  of  such  a 
measure  is  in  treating  the  delicate  and  in  feeding  difficult  cases,  rather 
than  well  babies,  who  thrive  regardless  of  the  carbohydrate  employed. 
The  maltose  preparations,  then,  in  the  sense  that  they  may  contain 
a  small  amount  of  proteid  and  a  laxative  sugar,  are  useful  and  to  be 
recommended  when  such  a  carbohydrate  is  needed. 

The  Proprietary  Beef  Foods. — Numerous  preparations  of  this 
nature  are  on  the  market,  and  there  has  been  abundant  opportunity 
to  test  their  value.  Without  going  into  a  lengthy  discussion  as  to  how 
and  under  what  conditions  these  preparations  have  been  used,  it  is 
sufficient  to  say  that  as  means  of  nutrition  for  children  they  play 
a  very  unimportant  part.  Their  principal  use  is  in  illness,  in  which 
they  act  as  a  stimulant,  and  to  a  less  degree  as  a  food.  They  all  make 
weak  proteid  mixtures  when  diluted  so  that  the  child  can  take  them. 
The  possibility  of  supplying  any  great  amount  of  nutrition  to  the 
economy  by  their  use  is  impossible;  occasionally,  however,  they  may 
be  used  to  advantage.  When  milk  is  withdrawn,  they  may  be  added 
to  the  cereal  gruel  substitute.  If  there  is  diarrhea,  great  care  must  be 
exercised,  as  the  proprietary  beef  preparations  as  well  as  beef-juice 
may  aggravate  this  condition.  On  account  of  the  creatinin  which  they 
contain,  these  foods  should  not  be  given  in  any  of  the  forms  of  neph- 
ritis. Another  feature  which  limits  their  use  is  that  a  child  soon 
tires  of  them.  They  can  rarely  be  given  more  than  two  or  three  times 
in  twenty-four  hours.  Valentine 's  is  the  preparation  I  usually  select. 
It  may  be  given  in  solution — one-quarter  to  one-half  teaspoonful  to 
six  ounces  of  the  diluent. 

CREAM 

Market  creams  are  known  as  "gravity  cream"  and  "centrifugal 
cream." 

Gravity  Cream. — Gravity  cream  is  obtained  by  allowing  the  milk  to 
stand  for  a  certain  length  of  time  and  then  removing  the  cream.     When 


74  THE    PRACTICE    OF    PEDIATRICS 

milk,  as  soon  as  it  is  drawn,  is  placed  in  a  quart  milk-bottle  or  fruit-jar 
and  kept  at  a  temperature  of  between  40°  and  50°F.,  most  of  the 
fat  will  have  risen  at  the  end  of  five  hours.  When  the  cream  is  care- 
fully removed  at  the  end  of  this  time,  from  0.3  to  0.8  per  cent,  of  fat 
will  remain  in  the  milk.  The  fat  content  of  gravity  cream  is  subject  to 
considerable  variation,  depending,  of  course,  upon  the  richness  of 
the  milk  and  the  manner  in  which  it  is  treated,  particularly  as  relates 
to  rapid  cooling.  In  the  cream  from  well-kept  grade  cows  the  fat  will 
average  about  16  per  cent.  In  cream  from  well-fed  Alderney  or  Jersey 
herds  it  may  be  as  high  as  20  per  cent.,  or  higher.  In  cream  from  cows 
indifferently  fed,  in  those  which  subsist  entirely  upon  poor  pasturage, 
the  fat  may  be  as  low  as  10  or  12  per  cent.  For  infant-feeding,  gravity 
cream  from  the  milk  of  grade  cows  is  preferred.  In  using  cream  for 
infant-feeding  all  the  cream  to  the  milk  line  should  be  removed,  as  the 
upper  layers  are  much  richer  in  fat  than  that  adjoining  the  milk. 
Further,  when  cream  is  mixed  with  milk  both  must  be  of  the  same  age, 
as  the  addition  of  older,  bacteria-laden  cream  to  fresh  milk  will  surely 
result  in  grave  digestive  disorders. 

Centrifugal  Cream. — Centrifugal  cream  is  that  which  is  removed  by 
an  apparatus  known  as  a  separator,  which  consists  of  a  circular  bowl  for 
holding  the  milk,  so  arranged  as  to  make  from  3000  to  5000  revolutions 
a  minute.  This  results  in  a  rapid  separation  of  the  lighter  fat  from  the 
milk.  The  fat  collects  near  the  center  of  the  bowl  and  is  removed  by 
a  device  arranged  for  this  purpose.  The  skimmed  milk  flows  outward 
from  another  portion  of  the  bowl  by  a  similar  device.  Centrifugal 
cream  is  more  difficult  of  digestion  than  gravity  cream  in  that  the 
natural  emulsion  in  which  the  fat  is  held  in  the  milk  is  destroyed  by  the 
process  of  centrifuging.  Centrifugal  cream  may  vary  greatly  in  its 
fat  content,  depending  upon  the  rapidity  of  operation  of  the  separator. 
According  to  Babcock  and  Russell,  the  proteids  also  undergo  a  change, 
which  does  not  add  to  their  nutritive  value. 

STERILIZATION  AND  PASTEURIZATION  OF  MILK 

The  sterilization  and  pasteurization  of  milk,  as  the  terms  imply,  are 
for  purposes  of  preservation.  The  term  sterilized  milk  is  applied  to 
milk  that  is  heated  to  the  boiling-point  and  maintained  at  that  tem- 
perature,— 212°F., — for  twenty  minutes.  The  effect  of  sterilization 
is  the  destruction  of  the  pathogenic  bacteria,  but  it  will  not  destroy 
the  spores.  Dr.  R.  G.  Freeman's  most  recent  observations  show  that 
heating  the  milk  to  140°F.  and  maintaining  it  at  this  point  for  one 
hour  is  of  advantage,  in  that  the  bactericidal  effects  are  as  good  as 
when  a  higher  temperature  is  used.  At  the  same  time  the  lower  tem- 
perature produces  less  chemical  change  in  the  milk.  Pasteurization 
consists  in  heating  the  milk  to  167°F.,  maintaining  it  at  that  tempera- 
ture for  thirty  minutes,  and  then  quickly  cooling  it.  The  effect  of 
sterilization  and  the  rapid  cooling  is  to  kill  the  existing  bacteria,  thus 
preventing,  temporarily,  further  bacterial  growth  in  the  milk. 


STERILIZATION   AND    PASTEURIZATION   OF  MILK 


75 


The  milk  which  is  boiled  in  a  bottle  which  is  properly  covered  is 
**  sterilized  milk, ' '  but  if  the  steriliza- 
tion is  to  be  carried  on  day  after  day 
an  Arnold  sterilizer  (Fig.  5)  should 
be  used.  For  purposes  of  pasteuriz- 
ation the  Freeman  pasteurizer  (Fig. 
6)  is  recommended.  Pasteuriza- 
tion makes  less  change  in  the  char- 
acter of  the  milk  content;  conse- 
quently there  is  less  interference  ' 
with  its  nutritive  value.  The  tem- 
perature, too,  167°F.,  is  sufficiently 
high  to  destroy  pathogenic  bacteria, 
including  the  Bacterium  lactis  and 
the  Bacterium  aerogenes,  and  hence 
acts  as  a  valuable  preservative, 
particularly  during  hot  weather. 

Pasteurization   Safest  for  Ex- 
clusive    Use. — The     question, 

whether  milk  should  be  given  steri-  Yig.  5. Arnold  sterilizer. 

lized,  pasteurized,  or  raw  has  given 

rise  to  endless  discussion  in  the  press  and  in  medical  societies.     Each 


Fig.  6. — Freeman  pasteurizer. 

method  has  its  advocates.     Among  the  podiatrists  at  the  present  time, 
some  contend  that  milk  should  be  sterilized,  regardless  of  the  season 


76  THE    PRACTICE    OF    PEDIATRICS 

of  the  year,  the  character  of  the  milk,  or  the  station  in  Hfe  of  the 
patient ;  others  maintain  that  invariably  it  should  be  given  raw,  regard- 
less of  the  above-mentioned  conditions;  while  still  others  are  devoted 
to  pasteurization.  If  any  of  the  methods  were  to  be  used  exclusively, 
pasteurization,  being  the  safest,  should  be  selected.  Judging  from  my 
own  experience  in  the  matter  of  the  heating  of  milk  for  infant  foods,  the 
subject  should  be  considered  from  a  broad  standpoint.  There  is  no  one 
way  of  heating  milk  that  is  invariably  the  best.  According  to  my 
observation,  there  are  several  factors  which  determine  which  is  the 
proper  procedure  in  a  given  case. 

Raw  Milk  Preferred  if  Fresh  and  Pure. — There  is  no  doubt  what- 
ever that  the  less  the  milk  is  heated,  the  better  food  it  is  for  the  average 
well  baby,  provided  it  is  clean  when  procured  and  can  be  kept  clean  and 
sweet  until  it  is  used.  (See  Cow's  Milk,  p.  49.)  This  is  possible  in 
some  of  our  dairi'es  of  the  better  class;  it  is  possible  with  many  who  live 
in  the  country,  or  who  go  to  the  country  for  the  summer  and  who  keep 
their  own  cows  or  who  get  their  milk-supply  from  a  neighboring  source 
which  they  can  control.  Under  such  conditions  the  milk  may  be  given 
raw  during  the  entire  year. 

When,  however,  the  milk  has  to  be  shipped  a  considerable  distance 
during  the  summer,  when  its  safety  depends  upon  the  industry  and 
carefulness  of  the  employees  of  a  milk-farm,  I  find  it  advisable  to  pas- 
teurize the  milk  during  the  heated  term;  therefore  the  majority  of  my 
private  feeding  cases  get  raw  milk  during  eight  months  of  the  year  and 
pasteurized  milk  four  months.  Sterilized  milk  is  never  used  among 
these  patients  except  during  an  ocean  journey  (see  Milk  for  Traveling, 
p.  69)  or  a  long-distance  journey  by  land.  Among  out-patients,  after 
feeding  many  thousands  of  them,  I  find  the  following  scheme  the  safest : 
From  May  1st  until  October  1st  the  milk  is  boiled  (sterilized).  These 
people,  most  of  them,  cannot  afford  a  pasteurizer  or  sterilizer  or  under- 
stand the  use  of  either.  From  October  1st  to  May  1st  the  milk  is 
given  raw.  Pasteurization  would  be  preferable,  but  it  is  possible  with 
but  very  few  dispensary  patients.  Even  the  giving  of  cooked  milk, 
which  unquestionably  often  becomes  infected  after  cooking,  is  attended 
with  no  little  risk  to  the  child,  as  is  shown  by  the  death  records  of 
bottle  babies  during  the  summer.  The  giving  of  the  cheap  market 
milk  raw  to  infants  of  the  tenements  during  the  heated  term  in  any 
large  city  can  only  help  to  increase  the  terrible  mortality  of  this 
season. 

The  object  of  heating  the  milk  should  always  be  explained  to  the 
mother  so  that  she  may  appreciate  the  necessity  of  keeping  it  carefully 
covered  and  properly  caring  for  it  afterward.  The  idea  is  prevalent 
among  uninformed  people  that  after  sterilization  but  little  further 
protection  is  required.  When  I  am  satisfied  the  out-patients  have 
not  the  requisite  intelligence  nor  the  means  for  keeping  cow's  milk 
during  the  summer,  such  as  an  ice-box  and  ice,  I  discontinue  the 
ordinary  milk-feeding  for  the  hot  months  and  use  condensed  milk  in- 
stead (p.  95). 


THE   EFFECT   OF  HEATING   MILK  UPON   ITS   ASSIMILATION         77 

THE  EFFECT  OF  HEATING  MILK  UPON  ITS  ASSIMILATION 

Concerning  the  treatment  of  milk  in  order  to  make  it  easier  of  utili- 
zation we  have  much  to  learn.  The  milk  proteids  lend  themselves  to 
influences  which  entirely  change  their  character,  and  affect  their  utili- 
zation by  the  infant.  The  heating  of  milk  influences  its  digestibility 
and  heating  with  different  substances  produces  further  changes  in  this 
respect. 

As  previously  stated,  evaporated  milk  is  easily  and  effectively 
utilized  by  the  infant  with  a  very  weak  digestive  system,  and  this 
milk  has  been  subjected  to  a  heating  process. 

A  certain  child  cannot  take  fresh  cow 's  milk,  modify  and  adapt  it  as 
we  will.  We  give  him  evaporated  milk  of  the  same  nutritional  value 
and  he  thrives.  This  I  have  demonstrated  in  many  private  cases  and 
at  the  Babies'  and  New  York  Nursery  and  Child's  Hospitals.  The 
digestive  ferments  were  unchanged  and  the  food  capacity  remained 
the  same ;  the  change  that  took  place  was  in  the  most  important  of  the 
milk  constituents,  the  proteid  content.  The  degree  of  heat  used  and 
the  length  of  its  application  also  have  a  controlling  influence  on  the 
digestibility  of  milk.  The  most  favorable  effects  are  produced  through 
heating  milk  in  the  presence  of  starch  and  an  alkali  or  antacid. 

For  example,  an  infant  suffering  from  malnutrition  is  given  a  for- 
mula of — 

10  ounces  milk  (top  15). 

1  ounce  milk-sugar. 
3^^  ounce  barley  flour  (Cereo). 
20  ounces  water. 
10  grains  bicarbonate  of  soda. 

The  food  agrees  to  the  extent  that  the  child  is  comfortable,  but  he  fails 
to  make  a  substantial  gain.  He  gains  and  loses  an  ounce  or  two  weekly. 
We  now  order  that  the  milk  and  the  barley  be  cooked  together  in  a 
double  boiler  for  thirty  minutes  and  that  water  be  added  at  the  com- 
pletion to  make  up  for  that  which  passes  off  in  evaporation.  The  food 
is  given  in  the  same  amount  at  the  same  interval,  and  at  once  the  child 
begins  to  take  on  weight.  The  feeding  schemes  have  been  identical 
excepting  that  in  the  latter  we  have  added  heat.  Such  an  outcome 
will  not  take  place  in  every  case,  but  I  have  demonstrated  this  effect 
time  and  again. 

Repeatedly,  when  an  infant  has  been  brought  to  me  because  of  mal- 
nutrition, although  the  child  was  getting  a  rational  cow's  milk  formula, 
I  have  continued  the  milk  strength  as  it  was,  simply  changing  the 
carbohydrate,  milk-sugar,  or  dextromaltose  to  starch  and  malt  soup, 
mixed  together  with  the  milk  and  cooked  for  thirty  minutes  in  a  double 
boiler.  The  same  carbohydrate  caloric  value  has  been  maintained ;  the 
food  has  been  given  in  the  same  amount  and  at  the  same  interval.  As 
a  result  of  such  changes  I  have  many  records  showing  a  prompt  and 
continuous  gain. 

In  many  cases,  every  year,  I  use  malt  soup,  starch,  and  milk  cooked 


78  THE    PRACTICE    OF    PEDIATRICS 

together  because  I  am  obliged  to  get  results.  I  use  the  evaporated  milks 
for  the  same  reason.  It  is  a  fact  also  that  a  combination  of  evaporated 
milk,  starch,  and  milk-sugar  and  bicarbonate  of  soda  will  be  better 
utilized  by  very  troublesome  cases  if  they  are  cooked  together.  In  like 
manner  I  use  malt  soup  and  starch  with  the  evaporated  milk. 

There  is  no  doubt  whatever  that  in  troublesome  feeding  cases  the 
heating  of  milk,  with  an  alkali  and  starch  renders  the  milk  easier  of  utiH- 
zation  by  the  infant.  Of  course,  the  milk  strength  has  to  be  carefully 
adjusted,  and  the  feeding  intervals  and  quantities  must  be  adapted 
to  the  age  and  weight  of  the  child.  Perhaps  stomach  washings  will 
be  required.  In  other  words,  the  physician  must  possess  judgment  as 
to  these  matters.  Not  a  little  of  the  success  attained  in  infant-feeding 
depends  upon  the  experience  and  judgment  of  the  physician. 

Frozen  Milk. — During  the  past  30  years  many  thousand  quarts  of 
frozen  milk  have  been  fed  to  infants  under  my  care.  In  no  instance 
has  it  been  demonstrated  that  frozen  milk  was  the  cause  of  illness. 
There  is  no  reason  for  the  belief  that  milk  which  has  been  frozen  dis- 
agrees with  the  average  bottle-fed  baby. 

SCIENTIFIC  INFANT-FEEDING 

I  was  recently  taken  to  task  by  a  young  colleague  for  using  evapor- 
ated milk,  malt  soup,  dextromaltose,  and  various  flours,  such  as  barley 
and  Imperial  Granum,  in  feeding  difficult  cases.  It  was  unscientific 
to  use  these  substances,  the  argument  maintained,  because  the  human 
breast  did  not  elaborate  evaporated  milk,  malt  soup,  barley  flour,  or 
dextromaltose.  Instead  of  such  substances,  fresh  cow's  milk,  lime- 
water,  milk-sugar  (Squibb's),  and  boiled  water  should  be  employed.  I 
replied  that  I  had  used  the  substances  enumerated  daily  for  twenty- 
five  years  and  had  fed  several  thousands  of  infants  on  fresh  cow's  milk, 
milk-sugar,  and  lime-water ;  while  in  my  experience  with  many  nursing 
mothers  in  institutions  and  in  private  work  I  could  not  recall  a  single 
instance  wherein  the  human  breast  had  secreted  fresh  cow's  milk,  lime- 
water,  or  Squibb's  milk-sugar. 

Scientific  infant-feeding  consists  in  supplying  a  balanced  ration  of  fat, 
proteid,  carbohydrate,  and  mineral  salts  in  an  assimilable  form  upon 
which  the  infant  makes  normal  development.  Neither  the  fat,  proteid, 
nor  carbohydrate  must  be  of  one  invariable  form.  Nature  permits  of 
a  wide  latitude. 

In  function,  moreover,  the  fat  and  carbohydrate  are  interchange- 
able and  may  vary  widely  in  nature  and  in  quantity.  There  must, 
however,  be  a  fairly  definite  content  of  proteid  of  a  nature  that  admits 
of  its  utilization;  or  we  shall  have  varying  degrees  of  malnutrition  and 
marasmus;  for  without  nitrogen  and  other  proteid  constituents  cell 
growth  is  impossible.  By  the  use  of  starch  and  alkalis,  the  subjection, 
of  milk  to  the  influence  of  heat  of  varying  degrees,  and  by  other  means, 
we  may  change  the  nature  of  the  proteid  to  such  an  extent  that  the  in- 
fant may  utilize  the  food  in  a  manner  before  impossible. 


HABITUAL    LOSS    OF    APPETITE  79 

Idiosyncrasy  to  Food  Substances. — -Food  Allergy. — -Children  may 
show  idiosyncrasy  to  various  food  substances. 

Dr.  O.  M.  Schloss,*  of  New  York,  calls  attention  to  a  case  that  was 
sensitized  to  egg-white,  oatmeal,  and  almonds  to  such  degree  that  a 
cutaneous  reaction  occurred  to  these  substances.  Infants  and  young 
children  may  show  this  intolerance  to  any  food  containing  protein. 
During  the  past  18  months  I  have  tested  47  children  who  showed 
the  cutaneous  reaction  and  who  were  made  ill  when  egg  was  given. 
Eleven  of  my  patients  showed  a  cutaneous  reaction  to  milk,  9  reacted 
to  oats,  16  to  wheat,  9  to  rye,  and  10  to  barley.  A  considerable  experi- 
ence with  cutaneous  reaction  to  protein  has  shown  some  very  contra- 
dictory findings.  Children  are  not  always  made  ill  by  a  protein 
administered  by  the  stomach  that  may  produce  a  marked  cutaneous 
reaction.     Much  remains  to  be  learned  of  this  very  interesting  subject. 

HABITUAL  LOSS  OF  APPETITE 

The  growing  child,  like  the  adult,  not  only  requires  sufficient 
nourishment  to  sustain  life,  but,  in  addition  to  this,  an  extra  amount 
to  supply  the  demands  of  growth.  Proportionate  to  their  size, 
therefore,  all  growing  animals  require  more  food  than  do  those  that 
have  reached  maturity.  The  young  child  is  naturally  such  a  very 
hungry  animal  that  ample  feeding  is  absolutely  essential.  There- 
fore, when  there  is  habitual  loss  of  appetite  so  that  the  child's  entire 
life  may  be  unfavorably  influenced,  we  must  realize  that  the  condition 
is  abnormal  and  strive  to  discover  the  cause  and  apply  the  remedy. 

Physicians  are  often  consulted  by  parents  whose  children  are  suf- 
fering temporarily  or  persistently  from  loss  of  appetite — a  condition 
usually  associated  with  secondary  anemia  and  asthenia.  The  child 
apparently  is  not  ill :  he  may  be  active  and  playful,  but  he  tires  easily. 
The  sleep  ordinarily  is  sound  and  refreshing,  but  the  child  must  be 
coaxed  to  eat.  Oftentimes  he  will  take  food  only  when  his  attention 
is  diverted  by  a  story  or  a  toy.  He  usually  eats  for  the  entire  family, 
taking  a  mouthful  each  for  father  and  mother,  for  the  coachman, 
and  for  the  cook!  Three  or  four  times  a  day,  depending  upon  the 
number  of  meals,  this  coaxing,  entertaining  process  has  to  be  gone 
through.  Occasionally  children  with  habitually  poor  appetites 
for  food  in  general  will  have  a  history  of  excessive  milk-drinking. 
From  3  to  5  glasses  of  milk  may  be  taken  daily  and  all  other  food 
refused.  When  milk  forms  the  principal  or  only  article  of  nourish- 
ment after  the  eighteenth  month,  children  will  invariably  show 
evidences  of  malnutrition.  They  are  apt  to  be  pale  and  sallow,  with 
flabby  muscles.  The  most  frequent  cause  of  loss  or  lack  of  appetite 
is  too  frequent  feeding.  It  is  not  at  all  uncommon  to  see  children 
from  two  to  four  years  of  age  who  are  being  fed  six  or  seven  times  in 
twenty-four  hours,  the  argument  of  the  parents  being  that:  ''The 
child  takes  so  little  food,  he  ought  to  take  it  oftener."  With  increas- 
*  American  Journal  Diseases  of  Children,  vol.  iii,  p.  341. 


80  THE    PRACTICE    OF    PEDIATRICS 

ing  age,  more  and  stronger  food  is  required  at  less  frequent  intervals. 
In  other  cases  children  may  not  get  their  regular  feedings  at  such 
frequent  intervals,  but  are  generously  supplied  between  meals  with 
candy,  cake,  crackers,  and  fruits.  Unsuitable  food  may  be  the  cause 
of  a  habitually  poor  appetite.  Children  of  tender  age  who  are  regularly 
fed  from  the  adult  table  with  heavy  adult  food,  oftentimes  improperly 
cooked,  soon  suffer  from  loss  of  appetite.  Children  who  are  poor 
eaters  usually  have  the  associated  ailment,  constipation.  Too  close 
confinement  indoors  is  not  infrequently  associated  with,  if  not  a 
direct  cause  of,  lack  of  appetite.  Children  who  are  kept  uninter- 
ruptedly in  the  house  for  weeks  at  a  time  invariably  have  poor  appetites. 

Treatment. — In  order  to  emphasize  a  point  in  teaching,  when 
treatment  is  under  consideration,  I  have  sometimes  found  it  useful 
to  state,  first,  what  not  to  do.  Do  not  give  these  children  drugs  as 
a  means  of  inducing  an  appetite  until  all  other  means  have  failed. 
The  only  medication  that  should  be  permitted  is  some  simple  laxative. 
There  must  be  one  evacuation  of  the  bowels  daily.  The  aromatic 
fluid  extract  of  cascara  sagrada,  from  1  to  2  drams,  given  daily  at  bed- 
time, or  from  3  to  5  ounces  of  the  citrate  of  magnesia  given  before 
breakfast,  ordinarily  answers  well. 

Fresh  Air. — Every  "runabout"  child  should  spend  at  least  five 
hours  daily  in  the  open  air,  regardless  of  the  season  of  the  year.  Dur- 
ing very  inclement  weather  in  winter,  indoor  airing  (see  p.  760)  is  a 
most  satisfactory  substitute. 

Diet. — -An  important  step  in  the  treatment  is  the  regulation  of 
the  feeding  hours.  A  child  from  twelve  to  fifteen  months  old  requires 
five  feedings  daily  (see  Dietary,  p.  105).  Ordinarily,  for  "  runabout " 
children  from  the  fifteenth  to  the  twenty-fourth  month,  four  meals 
daily  are  necessary,  but  when  there  is  loss  of  appetite,  three  meals 
often  answer  best.  After  the  second  year,  three  meals  are  invariably 
the  rule  unless  the  child  is  weak  or  ill.  All  feedings  should  be  given 
at  a  definite  time  each  day,  from  which  there  should  be  no  deviation. 
Nothing  whatever  except  water  should  be  allowed  between  meals. 
My  next  step,  in  case  these  regulations  fail,  is  to  place  the  child  tem- 
porarily on  a  markedly  reduced  diet,  no  solid  food,  such  as  meat,  eggs, 
breadstuffs,  vegetables,  or  fruits,  being  allowed.  Milk,  gruels,  and 
broths  should  comprise  the  nourishment.  When  the  desire  for  food 
returns  the  regular  feeding  schedule  is  resumed.  The  mother  must 
be  given  the  directions  both  orally  and  in  writing. 

If  the  case  is  one  of  milk  habit,  then  the  milk  must  be  entirely  cut 
off,  and  broth,  thin  gruel,  dry  bread,  or  zwieback  substituted.  The 
mother  is  instructed  to  return  with  the  child  in  two  days.  In  the 
great  majority  of  instances  the  report  after  forty-eight  hours  is  that 
the  child  is  ravenously  hungry.  When  such  is  the  case  freer  feeding 
is  allowed,  but  under  the  same  strict  observance  of  feeding  intervals, 
with  absolutely  no  feeding  between  meals.  It  is  extremely  rare  to 
meet  a  case  of  habitual  loss  of  appetite  which  will  not  respond  to  this 
simple  method  of  treatment.     In  a  large  number  of  cases  of  failing 


SUBSTITUTES    FOR    STOMACH-FEEDING  81 

appetite  I  have  succeeded  in  restoring  the  desire  for  food  by  removing 
milk  largely  from  the  diet,  having  it  skimmed  and  given  in  small 
amounts,  morning  and  evening,  and  in  reducing  the  sugar  intake  to  a 
minimum.  Many  children  get  more  milk  than  is  good  for  them,  and 
practically  all  children  get  more  sugar  than  they  can  utilize  with 
benefit. 

Change  of  Climate. — Occasionally  a  child  is  brought  for  treatment 
who  fails  to  show  the  least  evidence  of  disease  and  yet  will  not  respond 
to  proper  dietetic  and  hygienic  measures.  For  such,  a  change  of 
climate  in  addition  to  proper  methods  of  feeding  has  been  found  ad- 
visable. A  change  from  the  city  to  the  country,  or  from  the  inland 
country  to  the  seashore,  has  been  followed  by  a  decided  improvement. 
When  such  changes  are  impossible,  or  when  proper  dietetic  regulations 
are  impracticable,  as  with  our  dispensary  patients,  medication  may 
be  of  service. 

Tonics.- — ^In  my  experience  the  best  medicinal  means  of  improving 
the  appetite  is  a  solution  of  citrate  of  iron  and  quinin  in  sherry  wine, 
1  grain  of  the  citrate  of  iron  and  quinin  being  dissolved  in  3^^  dram 
of  sherry  wine  and  given,  well  diluted,  before  meals.  This  dosage 
will  answer  for  children  over  eighteen  months  of  age.  For  younger 
children,  3^2  grain  of  the  citrate  of  iron  and  quinin  in  3^^  dram  of  sherry 
wine,  well  diluted,  may  be  given.  If  this  is  not  successful,  1  minim 
of  dilute  hydrochloric  acid,  3^^  minim  of  the  tincture  of  nux  vomica, 
and  2  teaspoonfuls  of  water  may  be  given  at  two-hour  intervals  to 
children  ov.er  fifteen  months  and  under  two  years  of  age.  After  the 
second  year  2  minims  of  the  dilute  hydrochloric  acid  and  1  minim 
of  nux  vomica,  in  3  teaspoonfuls  of  water,  may  be  given  at  two-hour 
intervals. 

There  remain  also  to  be  considered  under  this  head  not  a  few 
children  who  habitually  suffer  from  poor  appetite  and  are  below  the 
average  in  every  respect.  This  type  of  child  is  considered  in  detail 
under  "The  Care  of  the  DeHcate  Child"  (p.  123). 

SUBSTITUTES  FOR  STOMACH-FEEDING 

In  the  management  of  the  diseases  of  children  conditions  arise 
from  time  to  time  which  necessitate  the  nourishment  of  the  patient  by 
channels  other  than  the  stomach.  In  persistent  vomiting,  when  there 
is  an  acute  involvement  of  the  stomach,  as  in  an  acute  gastro-enteric 
infection,  in  cyclic  vomiting,  and  in  vomiting  due  to  some  more 
remote  cause,  as  meningitis  or  nephritis,  the  patient  must  receive 
water  and  food  in  order  to  sustain  the  system  until  the  exciting  factor 
is  removed. 

Nutrition  by  means  other  than  stomach-feeding  may  be  necessary 
in  retropharyngeal  adenitis  or  abscess,  in  stricture  of  the  esophagus,  in 
diphtheria,  in  the  exanthemata,  and  in  pneumonia  during  the  course  of 
active  delirium.  A  substitute  for  stomach-feeding  is  often  useful  in 
marasmus,  in  the  generally  delicate,  and  in  those  with  reduced  assimi- 
lative powers.  Various  means  of  substitute  feeding  have  been  at- 
6 


82  THE   PRACTICE    OF   PEDIATRICS 

tempted  from  time  to  time.  Nutritive  suppositories  have  been  advo- 
cated and  proved  failures,  perhaps  because  of  our  inabiHty  to  place 
them  sufficiently  high  in  the  bowel.  Placed  in  the  rectum,  they 
excite  peristalsis  and  are  expelled. 

Hypodermic  Feeding. — Hypodermic  feeding,  and  the  introduction 
of  food  into  the  circulation  are  unsafe  and  impracticable  in  the  treat- 
ment of  children. 

Feeding  by  Inunction. — Feeding  by  means  of  oil  inunctions,  by 
active  friction,  or  by  the  more  passive  means  of  wrapping  the  child  in 
oil-soaked  cotton  and  allowing  him  to  rest  in  it,  is  thought  by  many  to 
be  effective,  in  spite  of  the  fact  that  the  skin  is  an  organ  of  excretion, 
and  that  its  powers  of  absorption  are  very  slight.  I  am  convinced  that, 
for  infants  and  young  children,  the  inunctions  of  properly  selected  oils 
possess  distinct  nutritive  value,  more  benefit  being  derived  by  the  pa- 
tient than  can  be  attributed  to  the  lubrication  of  the  skin  and  the  mas- 
sage. The  rubbing  of  mercurial  ointment  into  the  skin  is  one  of  the 
most  familiar  means  of  introducing  mercury  into  the  circulation.  No 
one  will  dispute  the  efficacy  of  this  form  of  treatment.  Fat  inunctions 
are  useful  for  marantic  infants,  and  delicate  "runabouts"  with  low  fat- 
digestive  capacity.  In  chronic  diseases  also,  such  as  tuberculosis, 
syphUis,  and  rheumatism,  oil  inunctions  are  of  advantage.  They  may 
be  used  with  advantage  during  convalescence  from  the  severe  acute 
diseases,  which  have  not  only  reduced  the  patient's  weight,  but  have 
so  affected  the  digestive  and  assimilative  functions  that  a  return  to 
health  is  materially  retarded.  A  brine  bath  (p.  780)  should  precede 
the  inunctions,  which  are  best  given  at  bedtime.  If  possible,  an 
animal  fat  should  be  used.  Goose-oil  and  unsalted  lard  are  preferred. 
Cod-liver  oil  is  never  advised  on  account  of  its  very  disagreeable  odor. 
Olive  oil  may  be  employed  in  case  the  unsalted  lard  or  goose-oil  is  not 
obtainable.  Cacao-butter  is  the  least  desirable  of  all  fats  that  may  be 
used  for  this  purpose,  particularly  if  the  child  is  young  and  athreptic, 
for  the  reason  that  there  may  not  be  enough  bodily  heat  to  keep  the  oil 
fluid  after  it  has  been  rubbed  into  the  intercellular  spaces  and  hair- 
follicles.  For  children  under  one  year  of  age,  it  is  my  custom  to  direct 
that  one-half  ounce  of  goose-oil,  unsalted  lard,  or  olive  oil  be  rubbed 
into  the  skin  of  the  arms,  thorax,  legs,  and  back  immediately  following 
the  salt  bath.  The  rubbing  is  to  be  continued  until  the  oil  disappears, 
which  may  require  from  ten  to  fifteen  minutes.  The  rubbing  should  be 
done  with  the  palm  of  the  hand  and  not  with  a  brush  or  a  cloth.  In  a 
few  cases  it  is  difficult  to  have  the  oil  absorbed,  even  though  not  more 
than  one  dram  is  used.  This  condition  is  most  common  in  those  who 
most  need  the  oil — athreptics  with  low  temperature,  in  whom  the 
superficial  circulation  is  very  poor.  After  the  inunction  the  child 
should  at  once  be  put  to  bed.  For  older  children,  3^^  to  Ij-i  ounces  of 
the  oil  may  be  used.  How  much  will  be  required  for  the  ten  to  fifteen 
minutes'  rubbing  will  soon  be  learned.  In  these  cases,  also,  the  in- 
unction should  follow  the  brine  bath.  The  use  of  the  oil  inunction  in 
hundreds  of  cases  has  proved  its  efficacy.     How  much  of  the  beneficial 


SUBSTITUTES    FOR    STOMACH- FEEDING 


83 


effects  are  due  to  the  oil  as  a  food,  how  much  to  the  massage,  producing 
better  skin  action,  improving  the  nutrition  of  muscles  and  inducing 
better  sleep,  I  am  unable  to  say.  The  beneficial  effects  of  the  inunction 
are  probably  due  to  three  factors:  the  oil  acts  to  a  slight  extent  as  a 
food,  the  massage  increases  the  functional  activity  of  the  skin,  and  im- 
proves the  muscle  nutrition. 

Rectal  and  Colonic  Feeding. — Any  means  of  treatment  which  is 
disagreeable  both  to  patients  and  attendants,  and  difficult  of  execution, 
is  very  liable  to  fall  into  disfavor  unless  pronounced  beneficial  results 
are  the  rule.  While  absolutely  nothing  can  be  promised  so  far  as  sup- 
plying nutrition  by  this  means  is  concerned,  careful  observation  and 
experience  tell  us  that  in  a  certain  number  of  cases  the  measure  is  of 
much  value.  Whether  the  treatment  will  be  of  service  in  nourishing 
the  patient  can  be  determined  by  trial  only.  In  children,  particularly  in 
very  young  children,  on  account  of  the  ease  with  which  peristalsis  is 
excited,  nutrition  by  this  means  is  less  frequently  successful  than  in 
the  adult.  Nevertheless,  it  has  been  of  material  assistance  to  me  in 
many  a  trying  situation.  Not  a  few  of  the  failures  are  due  to  a  lack 
of  appreciation  of  the  details  of  the  procedure.     Directions  to  mothers 


Fig.  7. — Hard-rubber  piston  syringe. 

or  nurses  to  inject  a  certain  quantity  of  some  particular  food,  unless 
specific  instructions  are  given,  will  usually  be  carried  out  as  follows: 
A  hard  glass  or  rubber  tip  will  be  passed  into  the  rectum  from  one  to 
two  inches.  Through  this  the  fluid  will  be  forced.  In  a  very  few 
minutes,  perhaps  immediately,  the  bowel  will  empty  itself  into  the 
napkin  or  bed-pan,  the  enema  being  of  no  service.  This  is  what  may 
be  expected  and  what  will  happen  when  the  child  is  given  the  nutrient 
enema  in  this  way.  The  hard  tip  placed  within  the  anal  ring,  and  the 
fluid,  are  very  apt  to  excite  vigorous  peristalsis.  In  order  that  the 
nourishment  may  be  retained,  it  should  be  carried  high  up  into  the 
descending  colon.  The  advantages  of  this  method  are  two-fold:  it  is 
much  better  retained ;  and,  on  account  of  the  greater  surface  of  mucous 
membrane  with  which  it  comes  in  contact,  it  will  be  quickly  and  more 
completely  absorbed. 

How  to  Give  a  Nutrient  Enema. — The  nutrient  enema  is  best  given 
as  follows:  A  soft-rubber  catheter.  No.  18  American,  or  a  small  rectal 
tube,  adult  size,  is  used,  the  former  being  preferred.  The  catheter  or 
tube  is  slipped  over  the  small  tip  of  an  ordinary  fountain-syringe.  The 
tube  should  not  be  too  flexible  nor  yet  too  stiff.  If  too  flexible,  it  folds 
readily  on  itself  when  the  point  meets  with  any  resistance,  and  the 


84  THE    PRACTICE    OF    PEDIATRICS 

fluid  escapes  perhaps  an  inch  or  two  within  the  anal  opening.  If  the 
tube  is  too  rigid  or  if  force  is  employed,  the  mucous  membrane  and  the 
parts  may  very  easily  be  lacerated. 

The  position  of  the  child  while  the  enema  is  being  given  is  impor- 
tant. He  should  rest  on  his  left  side,  preferably  in  the  Sims'  position, 
with  the  buttocks  elevated  to  a  plane  at  least  four  inches  higher  than  the 
shoulders.  A  pillow  or  a  folded  blanket  covered  with  a  rubber  sheet 
should  always  be  available  for  this  purpose  if  a  bed-pan  is  not  at  hand. 
The  child,  if  old  enough  to  understand,  is  assured  that  no  harm  will 
come  to  him.  With  the  patient  in  position  and  an  assistant  to  hold 
him,  the  anus  is  covered  with  vaselin.  It  is  not  enough  to  oil  the  tube. 
The  tube  attached  to  a  fountain-syringe  is  warmed  and  well  oiled  and 
passed  into  the  rectum.  The  lower  end  of  the  bag  should  be  three  feet 
higher  than  the  child's  body.  There  may  be  some  straining  at  first, 
but  with  the  child  in  a  proper  position,  one  may  pass  a  tube  of  the 
right  degree  of  flexibility  high  into  the  intestine  in  a  few  seconds.  The 
tube  should  be  introduced  about  nine  inches — far  enough  at  least  to  be 
felt  in  the  descending  colon  when  the  fluid  is  allowed  to  pass  rapidly 
into  the  bowel.  When  the  bag  is  emptied,  the  tube  is  rapidly  with- 
drawn and  the  child,  although  allowed  to  change  to  the  dorsal  posi- 
tion, is  encouraged  to  rest  on  his  side.  In  any  event,  the  buttocks 
must  be  kept  elevated  for  at  least  one-half  hour.  In  using  small 
amounts  of  fluid  it  is  well  to  allow  for  the  quantity  which  may  remain 
in  the  tube  of  the  syringe  and  in  the  catheter  after  the  enema  is  given. 
In  managing  older  children,  who  exert  much  bearing-down  or  strain- 
ing, it  may  be  necessary  to  attach  the  catheter  to  a  Davidson  syringe 
or  to  an  ordinary  rubber  (Fig.  7)  or  glass  piston-syringe  of  large  size, 
in  order  to  provide  sufficient  force  to  overcome  the  pressure  exerted  by 
the  abdominal  muscles. 

The  nutriment  should  be  neither  too  hot  nor  too  cold.  With 
either  of  these  extremes,  peristalsis  is  apt  to  be  excited.  I  have  found 
a  temperature  of  95°F.  to  be  the  most  satisfactory.  If  bowel  action 
has  been  fairly  free,  previous  washing  with  a  normal  salt  solution  is  not 
necessary.  If  there  has  been  no  movement  for  six  hours,  it  will  be  well 
first  to  use  an  irrigation  of  normal  salt  solution.  Glycerin  should  not 
be  used.  The  irrigation  should  precede  the  enema  by  from  fifteen 
minutes  to  half  an  hour. 

Nourishment  Not  to  he  Used  in  the  Rectum. — Oils  or  fats  in  any  form, 
even  though  pancreatinized,  should  not  be  used.  Alcohol  should 
be  used  only  in  very  urgent  cases,  and  then  it  should  be  well  diluted 
and  used  not  oftener  than  once  or  twice  in  twenty-four  hours.  It  has 
a  decidedly  irritant  action  on  the  intestinal  mucous  membrane  and 
is  not  well  retained.  When  used,  it  should  be  diluted  with  from  12  to 
16  parts  of  water  or  an  equal  quantity  of  skimmed  milk,  which  has 
been  peptonized  or  pancreatinized.  In  giving  stimulants  by  the 
rectum,  whisky  is  usually  employed  in  quantities  from  one-fourth  ounce 
for  a  child  two  years  of  age,  to  one  ounce  for  a  child  from  six  to  ten 
years  of  age. 


SUBSTITUTES    FOR    STOMACH-FEEDING  85 

Nourishment  to  he  Used. — By  far  the  best  food  for  rectal  alimenta- 
tion is  skimmed  milk  completely  pancreatinized.  It  is  better  retained 
and  more  completely  assimilated  than  any  other  form  of  nutriment 
which  we  possess,  as  is  shown  by  its  results  in  maintaining  the  nutrition 
and  strength  of  the  patient.  In  cases  in  which  it  is  desired  that  a  con- 
siderable amount  of  fluid  be  absorbed  by  the  intestine,  the  pancreatin- 
ized milk  may  be  diluted  with  a  normal  salt  solution.  Where  such  milk 
is  not  available,  the  whites  of  three  raw  eggs,  mixed  with  a  normal  salt 
solution,  may  be  given.  Not  infrequently  I  order  the  whites  of  one  or 
two  raw  eggs  given  in  the  pancreatinized  skimmed  milk,  believing  this 
combination  gives  us  the  best  form  of  nutrient  enema.  The  predigested 
proprietary  preparations,  the  so-called  "peptones,"  have  not  been 
satisfactory  in  my  hands. 

The  amount  of  nourishment  to  be  used  at  one  time  varies  with  the 
age  and  condition  of  the  child. 

ORDINARY  AMOUNT   TO   BE   GIVEN  IN  ENEMA 

Under  three  months 2-  4  ounces 

From  three  to  six  months 4r-  6  ounces 

From  six  to  twenty-four  months 6-  8  ounces 

After  the  twenty-fourth  month 8-16  ounces 

Because  the  first  enema  is  not  retained,  it  does  not  follow  that  a 
second  given  immediately  thereafter  will  share  the  same  fate.  In  not 
a  few  instances,  when  I  have  given  the  second  enema  ten  minutes  after 
all  or  the  greater  part  of  the  first  had  been  expelled,  the  entire  second 
amount  has  been  retained.  It  is  rarely  wise  to  repeat  the  enema 
oftener  than  at  six-hour  intervals;  and,  when  the  intestine  shows  a 
tendency  to  intolerance,  the  intervals  should  be  increased  to  eight  or 
ten  hours. 

This  means  of  nutrition  in  children  is  of  temporary  use  at  best. 
The  period  of  its  application  in  the  average  case,  even  when  tolerated 
at  first,  is  only  two  or  three  days.  In  a  few  instances  I  have  been  able 
to  use  the  method  longer. 

Illustrative  Cases. — During  the  summer  of  1903  a  very  delicate  three-months- 
old  child  under  my  care,  weighing  six  pounds  and  ten  ounces,  retained  two  ounces 
of  completely  pancreatinized  skimmed  milk,  given  at  six-hour  intervals  for  three 
days,  and  three  ounces  at  eight-hour  intervals  for  eight  days  longer,  making  a 
period  of  eleven  days  in  which  the  enemata  were  employed.  Such  tolerance  of 
the  large  intestine,  however,  is  very  rare. 

In  another  case  the  use  of  enemata  following  an  operation  for  intestinal  ob- 
struction with  protracted  vomiting  and  prostration  unquestionably  saved  a  child's 
life. 

In  a  recent  severe  case  of  cyclic  vomiting,  which  was  seen  in  consultation, 
the  vomiting  had  persisted  for  three  days.  This  child  was  six  years  of  age.  He 
showed  marked  emaciation,  and  suffered  from  intense  thirst;  his  pulse  was  weak 
and  soft.  A  nutrient  enema  was  given,  composed  of  eight  ounces  of  pancreatin- 
ized skimmed  milk,  eight  ounces  of  normal  salt  solution,  and  the  whites  of  two 
eggs.  Not  one  drop  was  expelled.  In  one-half  hour  the  boy  claimed  to  feel 
better.  The  intense  thirst  was  relieved  and  he  fell  into  a  restful  sleep.  In  six 
hours  the  enema  was  repeated,  about  four  ounces  being  expelled.  This  was  fol- 
lowed by  enemata  at  eight-hour  intervals,  eight  ounces  of  the  milk  with  the  whites 
of  two  eggs  being  given,  all  of  which  was  retained.  At  this  point  the  vomiting 
abruptly  ceased  and  further  enemata  were  not  required. 


86  THE    PRACTICE     OF    PEDIATRICS 

DISORDERS  OF  NUTRITION 
MARASMUS  (ATHREPSIA;  INFANTILE  ATROPHY) 

Under  the  title  of  marasmus  will  be  considered  those  cases  which 
are  associated  with  and  dependent  upon  derangement  of  function  of 
the  gastro-enteric  tract.  Tuberculosis,  syphilis,  and  atelectasis  are 
consequently  excluded,*  these  affections  being  considered  elsewhere 
under  their  respective  headings. 

Age. — Marasmus  is  seen  most  frequently  in  young  infants  under 
nine  months  of  age.  Cases  are  frequently  seen,  however,  from  the 
ninth  to  the  twelfth  month,  and  comparatively  few  between  the 
twelfth  and  eighteenth  months. 

Pathology. — There  is  no  lesion  or  set  of  lesions  peculiar  to  infantile 
atrophy.  I  have  personally  autopsied  a  large  number  of  cases.  There 
is  often  a  strip  of  hypostatic  pneumonia,  perhaps  a  large  area  of  atelec- 
tasis. Now  and  then  the  liver  is  fatty  or  shows  fatty  areas.  The 
spleen,  kidneys,  and  heart  are  pale.  The  stomach  and  intestines  con- 
tain thick,  sticky  mucus,  which  when  removed  shows  a  pale,  washed- 
out-appearing  mucous  membrane.  Blood  infections  with  the  pyogenic 
cocci  have  explained  the  etiology  in  several  recent  cases. 

Etiology. — A  great  deal  of  research  work  has  been  done  among 
marasmic  infants  in  order  to  determine  the  nature  of  the  condition, 
but  as  yet  no  satisfactory  explanation  has  been  offered.  The  disease 
is  unquestionably  due  to  defective  intestinal  assimilation.  The  prin- 
cipal fact  that  disproves  the  existence  of  any  atrophic  condition  or 
any  necessarily  severe  derangement  of  function  is  that  these  patients 
very  often  make  complete  recoveries,  becoming  perfectly  normal  chil- 
dren after  three  months  or  more  of  treatment. 

The  Usual  History. — The  history  of  these  cases  is  as  follows :  The 
mother  could  not  or  did  not  nurse  the  baby.  The  child  was  put  on 
cow's  milk,  which  was  usually  given  too  strong  or  in  too  large  quanti- 
ties— oftentimes  both  errors  were  combined,  or  the  milk  may  have  been 
too  old  when  used,  and  improperly  cared  for;  in  any  case  the  milk 
disagreed,  the  child  was  made  ill,  there  was  loss  in  weight,  cow's  milk 
was  discontinued,  and  one  of  the  infant  foods,  alone  or  combined  with 
milk,  was  given;  but  the  child's  digestion  being  thoroughly  disordered, 
the  foods  failed  to  agree.  There  was  vomiting  or  regurgitation,  with 
undigested,  green  stools,  or  both  combined,  while  the  loss  in  weight 
continued.  The  child  may  have  been  inherently  weak  or  may  have 
shown  a  cow's-milk  idiosyncrasy  to  help  account  for  the  lack  of  success 
in  the  milk-feeding.  Usually  there  followed  a  series  of  experiments 
with  different  kinds  of  food  and  methods  of  feeding,  the  vomiting, 
diarrhea,  or  colic  continued  with  wasting,  and  when  the  child  reached 
the  hospital  or  office  he  was  perhaps  six  months  of  age  and  weighed 
from  6  to  9  pounds,  presenting  a  typical  athreptic  picture.  Some  of 
these  children  are  born  with  a  digestion  that  is  apparently  incompati- 
ble with  cow's-milk  mixtures.  Others  have  their  digestive  capacity 
for  cow's  milk  hopelessly  deranged  by  improper  feeding  methods.     The 


maIiasmus  (athrepsia;  infantile  atrophy)  87 

majority  of  the  cases  occur  among  the  overcrowded  tenement  poor — 
the  worst  possible  environment  for  a  delicate  infant.  There  is  little 
or  no  proteid  assimilation,  so  that  any  approximation  to  normal  growth 
is  impossible.  They  may  also  possess  a  poor  fat  capacity,  and  if  there 
is,  in  addition,  a  diminished  sugar  capacity  the  proteids  of  the  tissues 
are  drawn  upon  to  supply  heat  and  energy,  with  resulting  progressive 
emaciation.  Heredity,  environment,  and  the  season  of  the  year  all 
influence  the  prognosis. 

Infection  as  a  Contributing  Factor  in  Marasmus. — In  our  manage- 
ment of  athreptics  we  have  been  so  occupied  with  nutrition  and  the 
gartro-intestinal  tract,  that  other  possible  etiologic  agencies  may  have 
been  neglected.  Occult  infections  may  and  do  play  a  very  decided  part 
in  some  of  these  cases.  Thus  during  a  recent  service  at  the  Babies* 
Hospital,  out  of  17  cases  in  which  blood  cultures  were  made,  5  were 
positive,  and  of  these  5  infants,  4  died.  Of  the  remaining  12  negative 
cases,  8  died,  and  of  the  4  that  recovered  1  had  an  otitis;  and  1,  a 
furunculosis  of  mild  degree,  while  the  remaining  2  had  no  demonstrable 
lesions.  Of  the  8  fatal  cases,  there  were  only  2  in  which  there  was  no 
evident  infection.  The  infection  varied  from  an  otitis  to  a  severe 
bronchopneumonia. 

The  blood  cultures  in  each  case  were  taken  when  the  infant  was 
losing  in  weight  and  apparently  retrogressing  without  any  digestive 
disturbances.  In  two  instances  the  clinical  evidence  (if  it  might  be 
called  such)  was  manifested  by  a  subnormal  temperature,  well-digested 
stools,  and  progressive  loss  in  weight.  In  two  others  there  existed  a 
temperature  and  later  signs  of  a  bronchopneumonia,  while  a  third 
showed  Klebs-Loffler  bacilli  in  the  nose.  Blood  counts  were  of  no  aid 
in  diagnosis. 

Marasmic  infants  who  fail  to  thrive  on  suitable  food  and  good  gen- 
eral management,  whether  there  are  evident  digestive  disturbances  or 
not,  should  be  thoroughly  examined  for  hidden  infections.  In  not  a 
few  of  those  who  show  progressive  loss  in  weight  there  has  been  a  sup- 
purative otitis  without  active  symptoms.  In  others  there  has  been  a 
bacteremia,  the  only  symptom  being  that  of  progressive  loss  in  weight. 

Pyloric  Obstruction  as  a  Cause  of  Marasmus. — During  the  past 
three  years  twenty-four  infants  have  been  seen  by  me,  showing,  nearly 
all  of  them  extreme  malnutrition.  They  gave  a  history  of  vomiting, 
usually  beginning  in  the  second  or  third  week  and  the  vomiting  con- 
tinued daily  with  marked  loss  of  weight,  constipation  and  no  fever. 
Thorough  examination  showed  that  these  cases  had  either  pyloric 
stenosis  or  spasm  of  the  pylorus,  or  both.  All  malnutrition  infants 
with  persistent  vomiting  should  be  examined  and  observed  to  deter- 
mine whether  or  not  there  is  trouble  at  the  pyloric  outlet. 

Treatment, — An  important  determining  factor  as  to  the  child's 
future  depends  upon  whether  or  not  he  can  have  the  advantage  of  a 
wet-nurse.  That  a  great  majority  of  the  cases  of  simple  athrepsia  re- 
cover, and  often  recover  promptly,  making  a  most  satisfactory  growth, 
when  a  wet-nurse  is  secured,  is  proof,  as  above  stated,  that  the  condi- 


88  THE    PRACTICE    OF    PEDIATRICS 

tion,  SO  far  as  relates  to  any  peculiar  systemic  state  or  pathologic  con- 
dition, depends  more  upon  the  nature  of  the  nutrition  than  upon  the 
patient.  In  securing  a  wet-nurse  the  physician's  duties  are  by  no 
means  completed.  The  patient  may  not  take  kindly  to  the  breast,  and 
will  have  to  be  taught  breast-nursing.  A  great  deal  of  time  may  be  re- 
quired in  teaching  older  infants,  those  who  have  been  on  the  bottle  for 
seven  or  eight  months.  To  this  end,  various  devices  may  have  to  be 
used.  For  the  first  nursing  it  is  well  to  allow  the  child  to  go  for  an  hour 
or  two  beyond  the  feeding-time  in  order  that  his  appetite  may  be 
voracious.  It  is  advisable  also  to  give  the  first  few  nursings  in  a  dark- 
ened room  with  the  person  who  has  been  accustomed  to  feeding  the 
patient  very  near.  Sufficient  milk  should  be  forced  from  the  breast  to 
enable  the  child  to  taste  it.  A  little  powdered  sugar  sprinkled  on  the 
nipple  is  a  good  means  of  increasing  his  interest.  In  some  instances 
it  has  been  necessary  to  cover  the  wet-nurse  with  a  blanket  or  sheet, 
leaving  only  the  breasts  exposed;  or  it  may  be  necessary  to  use  the 
nipple-shield  for  a  few  days  in  order  gradually  to  accustom  the  child 
to  the  change.  I  have  yet  to  see  a  case  in  which  success  did  not  follow 
persistent  effort.  Oftentimes  the  nurse's  milk  will  not  agree  at  first; 
but  this  is  not  surprising  and  need  cause  no  discouragement.  Breast- 
milk  ordinarily  is  a  much  stronger  food  than  the  child  has  been  accus- 
tomed to,  and  it  may  produce  vomiting,  colic,  or  diarrhea.  When 
indigestion  follows,  the  nurse's  milk  should  be  modified  by  giving  the 
baby  weak  barley-water  or  plain  boiled  water,  before  the  nursing  in 
case  he  nurses  well,  or  after  the  nursing  in  case  he  nurses  poorly.  One 
or  two  ounces  of  breast-milk  at  a  feeding  is  all  that  these  patients  can 
be  expected  to  take  during  the  first  few  days.  The  amount  obtained 
may  readily  be  determined  by  weighing  the  patient,  without  the 
trouble  of  undressing  him,  before  the  nursing,  and  then  weighing  him 
at  intervals  of  from  three  to  five  minutes  after  the  nursing  has  com- 
menced. An  ounce  of  breast-milk  is  practically  an  ounce  avoirdupois. 
These  children,  if  not  too  weak,  will  take  greedily  almost  anything 
from  the  bottle.  The  addition  of  an  ounce  or  two  of  barley-water  or 
plain  water  dilutes  the  milk  and  renders  it  easier  of  digestion,  and 
furnishes  at  the  same  time  the  necessary  fluid  for  the  child.  The 
most  unpromising  cases  of  marasmus  are  not  to  be  despaired  of  nor  the 
treatment  relaxed,  although  the  physician  should  be  cautious  in  his 
prognosis.  If  the  child  is  too  weak  or  indifferent  to  swallow,  the  wet- 
nurse's  milk  may  be  expressed,  diluted,  and  given  by  gavage.  In  many 
cases  evaporated  milk  (see  p.  95)  may  be  used  successfully  for  maran- 
tic infants.  It  is  much  easier  of  digestion  than  fresh  cow's  milk,  and 
is  a  temporary  measure  of  much  value. 

Hospitals  and  institutions  for  children  always  carry  a  certain 
number  of  these  unpromising  cases.  It  is  not  infrequent  to  find  miliary 
tuberculosis  at  autopsy  where  it  was  not  suspected  during  life,  no 
clinical  signs  of  fever  having  been  present. 

Illustrative  Case. — The  most  pronounced  and  the  most  hopeless  recovery  case 
coming  under  my  observation  was  seen  by  me  in  consultation  in  one  of  the  suburbs 


MARASMUS    (aTHREPSIA;   INFANTILE    ATROPHy)  89 

of  New  York.  The  child  was  four  months  old  and  weighed  5  pounds.  He  was 
emaciated  to  a  skeleton,  having  weighed  8  pounds  at  birth.  The  temperature  for 
several  days  ranged  between  92°  and  94°F.  A  trained  nurse  and  an  unusually 
intelligent  mother  were  in  charge.  I  doubted  the  accuracy  of  the  thermometer  read- 
ing, and  different  thermometers  were  used.  The  temperature  was  taken  by  the 
rectum.  I  took  the  temperature  on  one  or  two  occasions  with  my  own  ther- 
mometer and  found  the  reading  correct.  The  attending  physician  had  also  taken 
it  repeatedly,  so  that  finally  there  was  no  doubt.  The  child  was  too  weak  to  nurse. 
The  breasts  were  accordingly  pumped,  and  for  each  feeding  he  was  given  one-half 
ounce  of  breast-milk  with  an  ounce  of  barley-water,  to  which  a  few  drops  of  sherry 
wine  were  added.  This  was  given  by  gavage  at  two-hour  intervals.  He  was 
wrapped  in  flannel  and  wool  and  surrounded  with  hot-water  bottles.  The  food 
was  retained  and  digested.  In  four  days  he  could  nurse,  and  was  allowed  to  take 
a  small  amount  from  the  breast  and  finish  the  meal  with  barley-water.  The  tem- 
perature gradually  rose  to  the  normal.  More  breast-milk  was  allowed  as  he 
proved  able  to  care  for  it,  and  the  child  made  a  perfect  recovery,  weighing  18  pounds 
when  he  was  nine  months  old. 

This  case  demonstrated  to  me  that  a  marasmic  child  is  never  a 
hopeless  case  until  he  ceases  to  live.  Unfortunately,  very  few  marantic 
children  can  have  the  benefit  of  a  wet-nurse,  but  without  a  wet-nurse 
many  of  these  cases  are  not  hopeless.  The  use  of  condensed  milk 
(p.  95)  and  malt  soup  (p.  94)  will  furnish  a  satisfying  diet  in  not  a 
few  cases.  The  condition  is,  of  course,  a  very  serious  one,  but  the 
chances  are  much  better  in  a  reasonably  good  home  than  in  a  hospital, 
where  the  story  is  often  as  follows:  The  patients  take  the  modified 
milk  or  whatever  is  given  them  without  inconvenience.  The  stools 
may  be  offensive  if  cow's  milk  is  given,  or  there  may  be  constipation,  or 
the  stools  may  appear  perfectly  normal.  As  a  rule,  there  is  no  serious 
diarrhea  or  any  other  evidence  of  an  acute  inflammatory  process  in  the 
intestine.  However,  in  spite  of  fairly  normal  stools,  the  patient  grows 
thinner  and  thinner.  After  a  time  all  food  is  refused,  gavage  is  used 
as  a  last  resort,  and  the  child  finally  dies.  The  autopsy  shows  nothing 
but  pale  organs,  with  perhaps  a  strip  of  hypostatic  pneumonia.  Now 
and  then  one  of  these  cases  in  a  children's  institution  or  in  a  hospital 
recovers  without  a  wet-nurse,  but  it  is  the  exception  proving  the  rule. 
Put  these  athreptics  on  a  wet-nurse,  as  I  do  at  every  opportunity,  and 
many  of  them  thrive  in  spite  of  the  well-known  unfavorable  influence 
exerted  by  institutional  life  upon  the  very  young.  In  addition  to 
putting  the  athreptic  baby  on  the  wet-nurse,  his  stomach  should  be 
washed  once  daily  and  he  should  live  out-of-doors. 

Outdoor  Life. — Next  to  the  wet-nurse,  I  know  of  no  agent  fraught 
with  so  much  good  as  is  outdoor  life.  The  season  of  the  year  exerts 
considerable  influence  of  the  prognosis.  The  athreptic  bears  the  heat 
and  humidity  very  badly,  and  the  early  summer  mortality  of  all  large 
cities  is  materially  increased  by  these  children,  who  wilt  and  die  in 
institutions  and  tenements  with  the  first  two  or  three  days  of  continu- 
ous hot  weather.  Parents  residing  in  a  large  city  who  can  so  afford 
should  send  such  children  to  the  country  not  later  than  June  1st,  to 
return,  in  this  latitude  (New  York  City),  not  earlier  than  October  1st. 
During  the  day  the  child  should  be  on  a  porch  or  in  the  shade  con- 
tinuously. At  night  the  windows  of  his  sleeping-room  should  be  wide 
open.  During  the  cooler  months  if  the  child  is  too  ill  to  be  taken  out 
of  doors  he  should  have  from  morning  until  evening  a  continuous  in- 


90  THE    PRACTICE    OF    PEDIATRICS 

door  airing  (p.  20).  The  sleeping-room  should  always  communicate 
with  the  open  air.  The  roof-garden  in  large  cities  is  a  most  valuable 
aid  in  the  management  of  athreptic  children. 

Cases  in  Which  a  Wet-nurse  Is  Impossible. — While  much  has 
already  been  said  about  this  most  interesting  and  important  subject, 
one  phase  has  not  been  touched  upon.  I  refer  to  the  athreptic  infant 
of  the  tenement,  and  those  others  in  private  life  for  whom  a  wet-nurse 
is  impossible.  They  furnish  by  far  the  largest  number  of  our  marasmic 
patients.  Perhaps  the  most  frequent  error  in  the  management  of  these 
cases  is  an  endeavor  to  select  at  the  start  a  food  for  the  child  to  thrive 
upon.  In  doing  this,  almost  invariably  a  stronger  food  is  selected  than 
the  child  is  capable  of  digesting,  and  he  is  made  worse  by  the  attempt. 
Our  ultimate  object  in  treating  these  infants  will  be  more  readily 
attained  if,  at  first,  we  attempt  only  to  supply  a  food  upon  which  they 
can  exist  without  loss  in  weight.  The  number  of  calories  necessary 
for  an  athreptic  child  is  not  great.  It  must  be  remembered,  further- 
more, that  we  are  not  dealing  with  a  case  of  infant-feeding  as  the  term 
is  commonly  understood.  True,  we  are  feeding  an  infant,  but  a  sick 
infant,  and  the  methods  of  feeding  used  for  the  comparatively  well 
do  not  apply  here  in  all  respects.  The  problem  of  nourishing  these 
children  is  to  be  considered  from  two  standpoints — that  of  the  food 
and  that  of  the  baby,  with  special  reference  to  the  organs  of  digestion. 
The  stomach,  in  many  of  these  infants,  is  dilated,  with  a  consequent 
lack  of  motility.  Residual  undigested  food  remains  long  after  feeding. 
There  has  been  a  constant  fermentative  change,  with  the  production 
of  lactic  and  butyric  acids,  resulting  in  local  changes  of  an  inflamma- 
tory nature  in  the  mucous  membrane  of  the  stomach,  so  that  not  only 
must  the  organ  be  prepared  for  the  food,  but  the  food  must  be  adapted 
to  the  stomach  capacity,  and  when  this  is  done, — when  both  require- 
ments receive  due  consideration, — we  are  much  more  likely  to  succeed. 

Stomach-washing. — In  all  of  these  cases,  for  the  first  few  days  of 
treatment,  I  wash  out  the  stomach  with  sterile  water,  regardless  of  the 
presence  of  vomiting  and  regurgitation  and  regardless  as  to  whether  the 
child  is  bottle-fed  or  breast-fed.  It  is  often  surprising  to  note  the 
amount  of  thick  mucus  and  undigested  food  that  will  be  washed  from  a 
stomach  from  which  there  has  never  been  vomiting.  The  daily  wash- 
ings enable  the  child  to  take  more  food  and  stronger  food.  It  may  be 
necessary  to  continue  the  washings  for  days.  They  may  first  be  dis- 
continued when  the  water  siphons  clear  and  without  mucus.  They 
should  be  repeated  if  there  are  indications,  such  as  regurgitation  of 
sour  water  or  mucus  or  loss  of  appetite.  In  a  case  seen  recently  in 
which  there  was  chronic  gastritis  with  athrepsia,  washings  were 
continued  at  gradually  lengthened  intervals  for  six  months. 

Feeding. — If  the  case  is  one  with  pronounced  stomach  involve- 
ment, a  3  per  cent,  milk-sugar  solution  is  given  for  twenty-four  hours  in 
quantity  suitable  for  the  age  and  size  of  the  patient.  The  following 
day  barley-water  No.  1  (see  formulary,  p.  70)  is  given,  to  which  sugar 
is  added  to  make  the  mixture  5  per  cent. 


MARASMUS    (aTHREPSIA;   INFANTILE   ATROPHY)  91 

Cow's  Milk. — While  it  is  doubtful  if  the  child  can  take  cow's  milk 
after  this  period  of  stomach-rest  and  stomach-washing,  it  may  be  at- 
tempted. Two  drams  of  as  safe  milk  as  can  be  obtained  are  added  to 
every  second  feeding  of  the  barley  and  sugar  water.  If  it  agrees,  after 
a  day  or  two,  two  drams  are  added  to  each  feeding,  with  a  gradual 
increase  of  a  dram  every  two  or  three  days.  The  intervals  of  feeding, 
for  children  under  one  year  of  age,  may  range  from  two  to  three  hours. 
It  is  rarely  advisable  to  feed  even  the  most  delicate  athreptic  oftener 
than  once  in  two  hours.  If  the  milk  can  be  retained  and  assimilated 
in  the  strength  of  one-fourth  milk  and  three-fourths  barley  with  5  per 
cent,  sugar,  or  if  an  equal  quantity  of  milk  and  sugar-water  alone  is 
found  to  agree,  the  child  will  begin  to  grow  and  general  improvement 
will  rapidly  follow.  If  the  cow's  milk  is  not  well  borne,  skimmed  milk 
or  a  weak  cream  mixture — one-half  dram  of  cream  to  a  feeding — 
may  be  tried.  It  is  practically  impossible  to  have  whey  made  properly 
outside  of  a  hospital  laboratory  or  an  intelligent  home.  In  using  whey 
it  may  be  given  in  quantities  suitable  to  the  age  of  the  patient.  The 
prescribing  of  cream  among  the  poor  is  a  hazardous  procedure,  for  the 
cream  may  be  old,  improperly  cared  for,  and  swarming  with  bacteria. 
If  there  is  a  tendency  to  looseness  of  the  bowels,  the  diarrhea  is  thus 
made  worse.  Cream  mixtures  rarely  succeed  as  foods  for  athreptic 
children,  I  use  cream  only  among  those  who  can  properly  care  for  it. 
The  Peerless  Brand  (Borden)  (p.  96),  evaporated  and  unsweetened, 
may,  however,  often  be  used  with  success. 

Sweetened  Condensed  Milk. — I  have  found  that  for  the  out-patient 
athreptic  and  for  some  in  better  circumstances  the  much-abused 
condensed  milk  fulfils  a  useful  function.  It  is  the  cleanest  food  we 
can  give  the  dispensary  baby.  It  is  the  cheapest,  the  most  easily 
kept,  and  the  most  easily  digested  milk  that  can  be  furnished  him. 
Consequently,  when  ordinary  milk  feeding  is  impracticable  or  when 
it  disagrees,  I  give  condensed  milk,  beginning  with  one-half  dram, 
which  is  added  to  the  barley-water  or  to  the  plain  water  for  every 
second  feeding,  later  to  every  feeding,  increasing  the  quantity  gradu- 
ally as  the  child  shows  an  ability  to  digest  it.  The  patient  must  be 
seen  frequently  and  the  stools  carefully  examined  in  order  that  an 
increase  in  the  food  strength  may  be  made  as  soon  as  conditions  allow. 
The  mother  is  told  to  bring  the  napkins  to  the  dispensary,  and  the 
child  is  weighed  at  each  visit,  every  second  day.  It  is  most  gratifying 
to  see  how  well  some  of  them  gain  in  weight,  not  because  they  are 
getting  an  ideal  food  by  any  means,  but  because  the  food  used  tem- 
porarily fits  the  case.  Condensed  milk  is  thus  used  as  a  stepping- 
stone  to  something  better.  When  the  child  has  taken  condensed 
milk  with  benefit  for  a  month  or  six  weeks,  ordinary  milk  is  attempted 
if  the  time  of  the  year  is  between  October  and  the  following  June. 
After  June  1st  I  continue  with  condensed  milk,  as  the  possibility  of 
some  degree  of  anemia  and  rachitis  as  the  cooler  months  approach 
is  to  be  preferred  to  the  risk  of  attempting  cow's-milk  feeding,  with 
poor  milk,  in  the  hands  of  overworked  or  ignorant  mothers. 


92  THE    PRACTICE    OF    PEDIATRICS 

In  beginning  ordinary  milk,  in  order  to  avoid  sudden  radical 
changes  I  replace  one  feeding  of  the  condensed-milk  mixture  daily 
with  one  feeding  of  a  weak  plain  milk  mixture.  In  some  cases  this 
will  produce  illness  and  must  be  stopped;  in  others,  it  will  be  well 
borne.  When  it  is  found  to  agree,  two  feedings  should  replace  two 
condensed-milk  feedings  daily.  In  this  way,  by  increasing  by  one  the 
number  of  plain-milk  feedings  every  third  or  fourth  day,  entire  plain- 
milk  feeding  may  safely  be  inaugurated.  The  strength  of  the  plain 
milk  should  not,  of  course,  correspond  to  that  suggested  for  well 
babies.  To  a  child  of  six  months  a  three-months'  formula  may  be 
given.  As  the  child  improves,  the  strength  of  the  milk  may  corre- 
spondingly be  increased.  In  this  way  I  have  treated  successfully  a 
great  many  tenement  athreptics. 

Some  children  will  be  able  to  take  and  properly  care  for  only  two 
plain-milk  feedings  daily;  others  will  take  every  second  feeding  of 
plain  milk.  I  have  a  patient  at  the  present  time,  aged  fourteen 
months.  He  will  take  two  plain-milk  feedings  daily  with  comfort, 
but  when  the  third  is  given  he  is  invariably  made  ill.  Some  will  not 
be  able  to  take  a  particle  of  ordinary  milk.  When  this  is  the  case,  the 
condensed  milk  should  be  combined  with  a  gruel,  such  as  oatmeal, 
which  contains  a  high  percentage  of  proteid.  These  cases  may  also 
be  given  beef-juice  at  a  very  early  age.  I  often  use  pure  cod-liver  oil, 
from  15  to  30  drops  of  which  may  usually  be  taken  three  times  daily 
without  disturbance.  The  tenement  athreptic  is  given  the  benefit 
of  as  much  fresh  air  as  possible.  He  is  also  given  the  advantage  of 
the  daily  tub-bath  and  the  oil  rub.  For  further  suggestions,  see 
difficult  feeding  cases  (p.  94). 

MALNUTRITION  IN  INFANTS 

I  am  often  asked  by  students  the  difference  between  malnutrition 
and  marasmus  in  infants.  While  hard-and-fast  lines  cannot  be 
drawn  to  indicate  where  malnutrition  ends  and  marasmus  begins, 
there  is  a  vast  difference  between  the  two  conditions. 

Etiology. — Malnutrition  may  best  be  described  as  the  first  stage 
of  marasmus.  Every  child  with  marasmus  must  first  have  undergone 
a  longer  or  shorter  period  of  malnutrition.  Victims  through  in- 
heritance, such  as  those  who  are  constitutionally  rheumatic,  the 
offspring  of  the  tuberculous,  and  the  remotely  syphilitic,  often  show 
signs  of  malnutrition.  They  are  inherently  weak,  and  possess  low 
vital  resistance.  Frequent  child-bearing  may  be  a  predisposing  factor 
— the  fourth  or  fifth  child,  when  the  pregnancies  have  been  close 
together,  may  show  general  lack  of  vigor. 

Symptoms. — With  malnutrition  the  infant  may  be  three  or  four 
pounds  under  weight,  his  gain  being  slow  and  irregular;  often  inap- 
preciable, or,  at  best,  a  few  ounces  a  week.  The  muscles  are  soft, 
and  if  the  condition  persists,  bone  changes,  indicating  rachitis,  soon 
appear.     The  child  is  pale  and  usually  thin.     There  is  a  secondary 


MALNUTRITION    IN    INFANTS  93 

anemia.  Dentition  is  delayed.  The  hands  and  feet  are  apt  to  be 
cold,  and  the  skin  is  dry.  Excoriations  of  the  buttocks  and  intertrigo 
are  of  common  occurrence.  The  patient  shows  evidence  of  indiges- 
tion by  a  distended  abdomen  and  stools  that  are  far  from  the  normal. 
There  may,  however,  be  no  intestinal  derangement  whatever,  the 
malnutrition  being  due  to  the  fact  that  the  child's  diet  for  months 
has  consisted  of  food  that  did  not  contain  the  nutritional  elements 
required,  or  the  fact  that  he  was  unable  to  utilize  that  which  had  been 
given  him. 

A  case  due  to  high  fat  feeding  was  recently  seen  by  me.  The 
patient  was  a  male,  six  months  of  age,  weighing  13  pounds,  a  resident 
of  a  New  York  suburb,  where  the  conditions  are  most  healthful. 
His  fontanel  was  slightly  depressed,  the  muscles  were  soft  and  flabby, 
and  the  ribs  were  beaded.  The  child  had  lost  his  appetite  and  suf- 
fered from  constipation.  A  history  of  the  feeding  showed  that  he 
had  been  getting  a  cow's-milk  mixture  containing  approximately  6 
per  cent,  fat,  4  per  cent,  sugar,  and  2  per  cent,  proteid.  In  this  patient 
the  indigestion,  loss  of  appetite,  and  constipation  was  unquestionably 
due  to  the  high  percentage  of  fat.  The  energy  exerted  in  digesting 
the  food  almost  counterbalanced  the  benefit  derived  from  it,  the  result 
being  a  very  slow  gain  in  weight. 

Diagnosis. — Upon  assuming  the  care  of  one  of  these  infants,  one 
must  invariably  make  a  very  thorough  examination  in  order  to  de- 
termine whether  there  are  other  factors  than  that  of  imperfect  gastro- 
intestinal function.  Following  the  usual  physical  examination,  which 
should  include  the  ears,  the  urine  should  be  examined;  there  should  be 
a  von  Pirquet  test  for  possible  tuberculosis;  there  should  be  a  blood 
count  to  learn  the  degree  of  anemia  and  the  possibilities  of  occult  pus, 
and  if  the  case  is  very  persistent,  a  blood  culture  should  be  made,  as 
it  not  infrequently  occurs  that  a  hitherto  unsuspected  cause  of  mal- 
nutrition may  be  bacteremia.  In  my  hospital  cases  the  pneumococcus, 
the  streptococcus,  and  the  staphylococcus  have  been  found  in  the 
blood  in  malnutrition  babies. 

Treatment. — Diet. — The  management  of  malnutrition  due  to  such 
causes  consists  in  correcting  the  digestive  errors,  in  using  castor  oil 
or  calomel  with  stomach-washing,  and  in  adjusting  the  food  to  the 
child's  requirements  and  digestive  capacity. 

These  cases  are  all  difficult  to  feed  satisfactorily.* 

The  problem  which  confronts  us  is  often  most  difficult  of  solution. 

Chapin  is  an  advocate  of  the  use  of  cereal  gruel  as  a  milk  diluent, 
claiming  that  the  milk  is  rendered  more  easily  digested  because  of  the 
presence  of  the  starch.  Others  believe  that  the  use  of  alkalis  and  ant- 
acids renders  the  milk  easier  of  digestion.  Personally,  I  have  had  very 
little  success  in  fitting  such  special  modifications  of  fresh  cow's  milk  to 
difficult  cases.  In  very  few  of  these  difficult  cases  that  come  to  me  do 
the  ordinary  cow's-milk  dilutions  and  adaptations  produce  satisfactory 
results.  The  majority  are  infants  who  cannot  digest  cow's  milk  unless 
it  is  materially  changed  by  other  than  mechanical  methods.     It  is  also 


94  THE    PRACTICE    OF    PEDIATRICS 

to  be  remembered  that  in  difficult  feeding  the  food  is  only  a  part  of  our 
troubles.  The  physical  condition  of  the  child,  his  care,  and  particu- 
larly the  containing  and  working  capacity  of  the  stomach,  are  matters 
requiring  thought  and  adjustment.  Our  duties  do  not  end  with  a- 
change  or  series  of  changes  in  food. 
A  difficult  feeding  case  requires : 

1.  Fresh  air.     Indoor  airing  in  winter  or  roof  treatment — cold  air. 

2.  Clothing  sufficient  to  insure  warmth;  particularly  must  the 
extremities  never  be  cold. 

3.  Quiet — -absence  of  handling  other  than  is  necessary  for  clean- 
liness. Quiet  is  particularly  necessary  if  there  is  a  tendency  to  re- 
gurgitation or  vomiting. 

4.  Stomach  washing — a  most  useful  procedure,  even  when  there  is 
no  vomiting.  A  stomach  lavage  cleans  out  the  mucus  and  undigested 
material  from  the  stomach,  which  is  very  apt  to  be  enlarged  and  of  de- 
fective motility.  The  lavage  may  be  used  daily  for  a  week,  or  less  fre- 
quently— perhaps  every  other  day.  In  some  cases  one  or  two  washings 
suffice.  In  others  lavage  is  continued  at  intervals  determined  by 
the  condition — rarely  longer  than  three  to  four  weeks. 

5.  Position.  In  the  cases  with  habitual  regurgitation  the  position 
in  which  the  child  rests  in  the  crib  is  important.  Smith  and  Le  Wald* — 
as  a  result  of  six  Roentgen  ray  studies  of  infants  after  feeding — advise 
the  erect  position  after  feeding,  the  child  being  held  against  the  nurse's 
shoulder  for  a  few  moments.  When  the  child  is  placed  in  the  prone 
position,  the  head  of  the  crib  should  be  considerably  elevated.  Both 
of  these  proceedings  aid  in  the  expulsion  of  gas,  which  they  proved 
is  swallowed  during  the  act  of  nursing. 

Milk. — The  various  forms  of  so-called  peptonizing  processes  have 
obtained  very  little  success  in  my  hands,  and  I  rarely  employ  this  means 
and  do  not  advise  it. 

The  methods  that  have  been  useful  in  nourishing  these  infants  are 
as  follows: 

Whey  Feeding. — In  some  cases  the  feeding  of  whey  (p.  71)  may 
be  of  service.  This  means  is  not  of  very  general  application,  as  a 
milk  laboratory  or  a  very  competent  nurse  is  required  to  prepare  the 
whey. 

Malt-soup  Feeding. — The  use  of  malt  soup  for  infants  after  the 
fourth  month  is  of  much  value  in  treating  malnutrition  and  marasmus. 
For  very  young  infants,  also,  malt-soup  feeding  is  occasionally  appli- 
cable, although  the  feeding  of  children  before  the  third  month  by  this 
method  will  result  in  more  failures  than  successes. 

Contraindications  to  the  use  of  malt-soup  feeding  at  any  age  are 
vomiting  and  a  tendency  to  looseness  of  the  bowels.  A  considerable 
part  of  the  digestive  ailments  of  the  very  young  include  vomiting,  so 
that  this  symptom  must  be  controlled  before  malt-soup  feeding  is 
attempted.  In  feeding  an  infant  under  ten  weeks  of  age  in  whom 
vomiting  is  not  a  symptom  we  may  occasionally  use  malt  soup  with 
*  American  Journal  Diseases  of  Children,  vol.  ix,  pp.  261-282. 


MALNUTRITION    IN    INFANTS  95 

success.  The  patient  most  benefited  by  this  feeding  is  the  infant  after 
the  third  month  who  is  not  actively  ill,  but  who  fails  to  thrive  or  who 
is  made  actively  ill  by  the  use  of  the  ordinary  milk  modifications. 

I  have  had  many  children  brought  to  me  who  had  been  carefully 
fed  on  modified  cow's  milk,  in  whom  the  milk  had  produced  some 
disorder,  such  as  colic,  vomiting,  or  constipation.  Such  children  very 
frequently  appear  comfortable  and  take  the  food  eagerly,  but  make 
little  or  no  gain  in  weight  and  do  not  thrive.  They  are  pale,  thin, 
sleep  poorly,  and  are  underweight  two  to  five  pounds.  I  have  in 
hundreds  of  cases  used  the  identical  milk  formula  which  the  child  was 
getting,  and  simply  replaced  the  sugar  of  milk  or  the  cereal  flour  which 
furnished  the  carbohydrate  by  malt-soup  extract  and  some  flour  prepa- 
ration, with  the  resulting  prompt  response  of  a  gain  in  weight  of  four  to 
eight  ounces  weekly,  although  there  had  been  a  standstill  for  weeks. 

It  is  impossible  to  advise  any  definite  milk  strength  in  these  cases, 
as  the  condition  to  be  treated  is  abnormal,  and  wide  variations  in 
milk  strength  may  be  necessary.  In  general,  the  physician  may  select 
a  milk  formula  which  he  considers  applicable  to  the  patient's  weight 
and  condition,  and  then,  instead  of  using  cereals  or  milk-sugar,  use  the 
malt-soup  extract  after  the  following  manner.  We  may  suppose  that 
10  ounces  full  milk  daily  is  to  be  prescribed.  The  formula  will  read 
as  follows: 

10  ounces  milk. 

20  ounces  water. 

1}-^  tablespoonfuls  barley  flour  (Cereo  or  Robinson's). 

1  tablespoonful  malt-soup  extract. 

The  amount  and  feeding  intervals  are  the  same  as  for  other  methods 
of  feeding.  The  barley  is  mixed  with  the  milk;  the  malt  mixed  with  the 
water.  Both  mixtures  are  stirred  well  together,  placed  in  a  double 
boiler,  and  allowed  to  simmer  (kept  under  a  boil)  for  thirty  minutes. 
During  the  cooking  process  the  mixture  should  be  stirred  frequently. 
At  the  completion  of  the  cooking,  water  previously  boiled  is  added  to 
make  the  mixture  30  ounces.  This  is  strained  through  a  coarse-meshed 
strainer,  and  is  then  ready  for  use. 

If  the  child  shows  a  tendency  to  vomit  the  food,  the  malt  may  be 
reduced  one-half  temporarily,  or  skimmed  milk  may  be  employed. 
When  skimmed  milk  is  used,  from  two  to  four  ounces  more  should  be 
added  to  the  daily  supply  of  food  in  order  to  make  up  to  the  child  the 
loss  of  nutrition  entailed  by  removal  of  the  cream.  As  the  food  is 
found  to  agree,  the  milk  strength  may  be  gradually  increased. 

Condensed  Milk. — A  satisfactory  method  of  starting  difficult  feed- 
ing cases  toward  recovery  consists  in  the  use  of  condensed  or  evaporated 
milk. 

Condensed  milk  is  in  the  market  in  three  forms — fresh  condensed 
milk  sold  in  bulk,  condensed  milk  to  which  cane-sugar  is  added,  sold 
in  hermetically  sealed  cans,  and  evaporated  milk  without  the  addition 
of  sugar,  sold  in  hermetically  sealed  cans.     The  best  known  and  most 


96  THE    PRACTICE    OF    PEDIATRICS 

readily  available  brands  are  Borden's  condensed  milk,  known  as  the 
Eagle  brand,  and  Borden's  evaporated  milk,  known  as  the  Peerless 
brand.  The  Eagle  brand  contains  cane-sugar  in  considerable  amount, 
and  is  rarely  used.  The  Peerless  brand  is  evaporated  milk  without  the 
addition  of  sugar.  In  the  condensing  process  the  milk  is  heated  to 
200°F.  It  is  then  transferred  to  vacuum  pans,  where  it  is  maintained 
at  a  temperature  of  125°F.  until  sufficient  water  is  evaporated  to  bring 
the  product  to  the  required  condensation. 

The  analysis  of  the  Eagle  brand  is  as  follows: 

Fat 9.5    per  cent. 

Sugar 54.67   " 

Total  proteid 7.84   "       " 

Ash 1.68   " 

Water '. 27.31    " 

The  analyses  of  Peerless  brand  evaporated  milk  and  the  unsweetened 
condensed  milk  sold  in  bulk  are  very  similar.  The  standard  main- 
tained is  as  follows: 

Fat 8.3    per  cent. 

Sugar 10.05    " 

Proteid 7.1      " 

Ash 1.43   " 

Water 73.12    "       " 

In  using  condensed  milk  for  feeding,  that  known  on  the  market  as 
evaporated  milk  should  be  used.  In  using  this  variety  it  must  be  re- 
membered that  a  fresh  can  must  be  opened  daily.  The  fact  that  this 
milk  is  free  from  added  sugar  makes  possible  the  feeding  of  a  larger 
amount.  One  part  of  the  milk  to  three,  five,  six,  or  more  parts  of 
diluent  may  be  used.  Thus,  the  formula  for  a  day's  food  would  read 
like  the  following: 

7  ounces  evaporated  milk. 
28  ounces  water. 

starch  \        f  starch. 


carbohydrate        ,  t        i        i-  x      ^ 

I  sugar   J         I  malt-soup  extract. 

10  grains  bicarbonate  of  soda. 

Milk  of  this  strength  affords  a  nutritional  value  of  1.66  per  cent,  fat, 
1.43  per  cent,  proteid,  2.01  per  cent,  sugar.  To  this  mixture  carbo- 
hydrate in  the  form  of  starch,  cane-sugar,  dextromaltose,  milk-sugar, 
or  malt-soup  extract  may  be  added  to  raise  the  total  carbohydrate  to 
6  or  7  per  cent.  If  malt  soup  and  starch  are  used,  cooking  will  be  re- 
quired. (See  Malt-soup  Feeding,  p.  94.)  More  or  less  of  the 
evaporated  milk  may  be  used  as  may  be  required.  Many  infants 
of  very  weak  digestion  will  thrive  on  the  evaporated  milk  thus  given 
when  all  other  artificial  methods  fail.  To  the  very  yo.ung,  and  those 
with  poor  digestive  capacity,  and  to  athreptics,  a  lesser  amount  of 
milk  may  be  given  at  first, — one  part  of  milk  to  seven  or  eight  of  diluent, 
— the  quantity  being  increased  as  the  infant  shows  improved  capacity. 

As  the  child  grows  older  and  increases  in  weight  the  amount  of 
evaporated  milk  may  be  increased.     I  have  never  given  a  stronger 


MALNUTRITION    IN    INFANTS 


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98  THE    PRACTICE    OF    PEDIATRICS 

formula  than  14  ounces  of  the  evaporated  milk  (Peerless  brand),  26 
ounces  water,  carbohydrate  to  6  or  7  per  cent.  The  weight  chart  (see 
Fig.  8)  shows  the  progress  made  by  a  child  on  this  scheme  of  feeding. 
Notes  on  the  chart  indicate  when  the  evaporated  milk  feeding  was 
begun  and  the  various  strengths  used.  Previously  the  child  had  been 
given  various  fresh  cow's  milk  formulas. 

In  not  a  few  cases  the  food  will  be  better  assimilated  if  the  entire 
mixture — milk,  starch,  sugar,  and  soda — is  kept  just  under  the  boiling- 
point  in  a  double  boiler  for  thirty  minutes.  Occasional  stirring  is 
necessary,  and  at  the  completion  of  the  heating  process  water  should 
be  added  to  bring  the  food  to  the  original  amount. 

Plain  Milk. — When  the  child  has  remained  comfortable  for  six  to 
eight  weeks  or  longer  on  such  feeding,  almost  always  with  a  gain 
in  weight,  one  feeding  daily  of  a  plain  milk  mixture  may  replace  a  feed- 
ing of  condensed  milk.  A  raw  milk  mixture  should  always  be  given 
in  weaker  strength  than  the  child's  age  calls  for.  In  spite  of  the 
dilution  it  may  occasion  indigestion,  colic,  and  the  passage  of  curds. 
In  such  an  event  the  condensed  milk  and  its  diluent  must  again  be  the 
sole  diet  for  two  or  three  weeks,  when  the  use  of  ordinary  milk  may  again 
be  attempted.  After  a  few  days  or  a  week,  in  case  one  such  feeding 
is  taken  without  inconvenience,  a  second  feeding  may  replace  another 
condensed  milk  feeding.  In  this  way  the  number  of  plain  milk  feed- 
ings may  be  gradually  increased  until  the  child  is  taking  a  rational 
diet  of  this  milk  alone.  A  six-months '-old  baby  took  daily  three  feed- 
ings of  condensed  milk  and  three  of  raw  milk.  Attempts  were  made 
to  give  him  the  fourth  feeding  of  raw  milk,  but  invariably  with  dis- 
astrous results.  He  was  slightly  under  weight,  but  in  a  fair  general 
condition. 

I  have  successfully  managed  a  great  many  of  these  difficult  feeding 
infants,  as  described  above,  withholding  ordinary  milk  feeding  until  the 
child  is  taking  the  condensed  milk  well  and  gaining,  then  gradually 
advancing  the  raw  milk  feeding  until,  when  the  child  is  five  or  six 
months  old,  he  will  be  taking  daily  and  assimilating  two  or  three  feed- 
ings of  the  fresh  milk.  When  six  months  old,  and  sometimes  earlier, 
he  may  be  given  suitable  raw  milk  feedings  exclusively.  I  have  found 
that  by  the  above  method  the  desired  end  of  complete  plain  milk 
feeding  is  reached  sooner  than  when  small  quantities  of  cow's  milk 
are  added  to  the  condensed  milk  mixture. 

In  beginning,  it  is  best  to  give  the  raw  milk  at  the  first  or  second 
feeding  in  the  morning,  when  the  digestive  powers  are  stronger  than 
they  are  later  in  the  day.  When  the  second  raw  milk  feeding  is  given, 
it  should  never  immediately  follow  the  first.  The  raw  milk  and  the 
condensed  milk  should  be  alternated  until  more  than  one-half  of  the 
daily  feedings  are  of  fresh  milk. 

Idiosyncrasies  to  Cow's  Milk. — In  rare  instances  cases  are  en- 
countered in  which  there  exists  an  intolerance  of  cow's  milk  or  any 
form  of  food  which  contains  cow's  milk,  including  condensed  milk  and 
all  the  malted  foods  containing  desiccated  cow's  milk.     In  such  cases 


MALNUTRITION    IN    INFANTS  99 

the  use  of  any  of  these  substances  as  foods  produces  illness  of  such  an 
alarming  type  as  to  necessitate  prompt  discontinuance  of  the  food. 
The  only  hope  for  infants  thus  constituted  is  a  wet-nurse. 

Illustrative  Cases. — An  illustration  of  allergy  to  milk  foods  occurred  in  my  own 
family.  A  healthy,  full-term  female  infant  whose  birth-weight  was  7  pounds  12 
ounces  was  nursed  by  her  mother  with  indifferent  success  for  two  weeks,  when  the 
supply  failed  absolutely.  Feeding  with  a  most  carefully  prepared  modified  cow's 
milk  was  begun.  The  child  refused  the  food,  and  two  drams  were  forced.  This 
was  followed,  in  a  few  moments,  by  vomiting  and  retching,  which  continued  at 
intervals  for  twenty-four  hours,  with  collapse  and  exhaustion  to  an  extreme  degree. 
A  wet-nurse  was  secured,  the  breast  was  well  taken,  and  the  milk  agreed  perfectly. 
In  three  days  the  wet-nurse's  milk  began  to  fail  and  was  entirely  lost  in  twenty-four 
hours.  A  weak  dilution  of  condensed  milk  was  then  given,  with  results  almost  as 
disastrous  as  before.  The  child  at  this  time  weighed  6  pounds  4  ounces,  and 
showed  all  the  symptoms  of  early  marasmus.  A  second  wet-nurse  was  secured 
whose  milk  also  failed  in  a  few  days.  Before  her  departure,  however,  a  third  nurse 
was  engaged,  on  whose  milk  the  child  thrived  most  satisfactorily.  When  the 
patient  was  three  months  of  age  a  weak  cow's-milk  mixture,  prepared  by  the 
Walker-Gordon  Laboratory,  was  given.  The  child  refused  the  food,  and  one-half 
ounce  was  forced.  As  on  the  previous  occasion,  vomiting  with  prostration  border- 
ing on  collapse  was  the  outcome.  The  child  vomited  at  frequent  intervals  for 
twelve  hours,  and  the  breast  was  refused  for  twelve  hours  longer.  The  giving  of 
cow's  milk  was  not  again  attempted  until  the  child  was  nine  months  old,  a  wet- 
nurse  meanwhile  being  employed.  The  child  was  then  strong  and  vigorous,  and 
weighed  18  pounds.  Two  drams  of  cow's-milk  mixture  suitable  for  a  child  three 
months  of  age  were  given.  This  produced  nausea  and  vomiting,  as  though  an 
equal  quantity  of  syrup  of  ipecac  had  been  given,  but  no  more  serious  disturbance. 
At  this  time  the  wet-nurse's  milk  began  to  fail.  The  breast-milk  nutrition  was 
assisted  by  the  use  of  a  cereal  made  into  a  thick  gruel.  Oatmeal  in  the  form  of  a 
gruel  to  which  sugar  was  added  was  given,  largely  because  of  its  high  proteid 
content.  Beef-juice,  scraped  beef,  and  pure  cod-liver  oil  were  also  given  about 
this  time.  At  the  completion  of  the  first  year  a  portion  of  a  soft  egg  was  added  to 
the  diet.  Zwieback  and  bread-crusts  soaked  in  sugar-water  were  also  used. 
These  solid  substances  were  given  two  or  three  times  a  day,  after  which  the  child 
was  nursed.  Pure  cod-liver  oil  was  given  almost  continuously  during  the  second 
year.  Butter-fat  could  be  taken  without  inconvenience  when  she  was  one  year 
of  age.  Following  out  the  above  lines  of  treatment,  the  child  was  weaned  w^hen 
thirteen  months  of  age.  She  has  since  been  fed  with  an  entire  absence  of  cow's 
milk  from  the  diet.  When  six  years  of  age  her  weight  -was  55  pounds,  height  48 
inches.  She  was  normal  in  every  respect,  but  six  ounces  of  milk  given  at  one  time 
would  produce  a  coated  tongue,  foul  breath,  constipation,  and  excessive  irritability 
which  was  entirely  foreign  to  her  nature.  At  the  twelfth  year  the  intolerance  for 
milk  was  entirely  overcome. 

The  young  mother  of  a  vigorous,  eight-months'-old  breast-fed  girl  determined  to 
wean  the  baby.  The  family  physician  prescribed  a  suitable  formula.  The  child 
refused  to  take  the  milk  mixture.  A  small  quantity  was  taken  and  immediately 
vomited.  After  further  unsuccessful  attempts  at  feeding  two  ounces  were  forced. 
This  was  at  10  a.  m.  The  child  did  not  vomit,  but  passed  into  a  condition  approach- 
ing collapse.  When  I  saw  the  child  a  few  hours  later  she  presented  the  appearance 
of  a  case  of  severe  intestinal  intoxication.  She  w^as  very  apathetic,  but  could  be 
aroused  with  difficulty.  The  pulse  was  small,  very  soft,  and  thready.  The  res- 
piration was  superficial,  but  not  rapid.  The  eyes  were  sunken,  the  skin  blanched. 
In  spite  of  active  stimulation  and  external  heat  the  child  grew  gradually  weaker, 
making  but  tem.porary  response  to  stimulation,  and  died  seventeen  hours  after 
the  milk  had  been  given.  The  case  was  one  of  anaphylactic  shock  from  the  milk 
proteid.  I  have  seen  many  cases  of  allergy  to  foods,  but  this  case  is  my  only 
fatality. 

A  boy  whom  I  treated  for  colitis  gave  a  history  of  allergy  to  milk.  The 
placing  of  a  few  drops  on  his  tongue  would  be  followed  immediately  by  intense 
general  urticaria. 

A  vigorous,  nine-months'-old  breast  baby  was  given  a  feeding  of  cow's  milk  and 
vomited  it  at  once.  In  a  few  days  another  feeding  was  attempted.  The  child^took 
only  a  swallow  or  two  of  the  food,  but  at  once  developed  general  urticaria.  The 
ears  suddenly  became  several  times  their  normal  size,  and  the  eyelids  swelled  and 


100  THE    PRACTICE    OF    PEDIATRICS 

closed  the  eyes.  The  respiration  became  greatly  impeded  through  edema  of  the 
glottis  to  the  extent  that  the  mother  feared  the  child  would  suffocate.  I  saw  him 
six  hours  later;  the  voice  was  still  hoarse  and  croupy.  Three  weeks  later  five  drqps 
of  milk  were  placed  on  this  baby's  tongue.  In  three  minutes  he  vomited  and 
became  decidedly  pale;  in  a  few  minutes  more  he  vomited  again.  This  was 
followed  by  hiccup  which  lasted  until  he  left  the  office  one-half  hour  later.  The 
child  is  still  under  observation,  and  so  sensitive  is  he  to  milk  proteid  that  a  vac- 
cination with  milk  will  produce  at  the  site  of  the  scarification  a  large  urticarial 
wheal.  The  wheal  is  also  produced  by  egg-white.  Many  cases  show  intolerance 
to  milk,  but  in  lesser  degree. 

THE  AMMONIACAL  DIAPER 

Probably  every  physician  has  been  told  by  the  mother  or  nurse  that 
the  baby's  diaper  smells  of  ammonia.  South  worth  found  in  a  study  of 
several  cases  that  the  condition  was  readily  corrected  by  eliminating  or 
reducing  the  fat  in  the  milk  or  by  giving  alkalies,  such  as  magnesia  or 
citrate  of  potash. 

This  author,  quoting  Czerny  and  Keller  accounts  for  the  excessive 
ammonia  excretion  as  "depending  upon  the  chemical  property  of 
ammonia  to  combine  with  acids  as  an  alkaline  base.  While  under  nor- 
mal conditions  all  but  a  little  of  the  ammonia  becomes  urea  and  is 
excreted  as  such,  if  under  abnormal  conditions  there  is  present  in  the 
body  an  excess  of  unoxidized  acids  for  whose  neutralization  the  avail- 
able supply  of  fixed  alkalies  does  not  suffice,  the  ammonia  can  then  take 
the  place  of  fixed  alkalies  and  form  with  the  acids  ammonia  salts,  which 
will  be  excreted  in  the  urine." 

Treatment. — The  management  of  these  cases  as  suggested  above 
rests  in  reducing  the  fat  to  the  child's  capacity,  or  in  the  use  of  alkalies. 
In  my  own  cases  the  reduction  of  the  fat  content  in  the  food  has  been 
all  that  was  required.  A  reduction  of  2  per  cent,  of  fat  in  the  food 
mixture  will  usually  suffice  to  correct  the  condition. 

TARDY  MALNUTRITION  AND  MALNUTRITION  IN  OLDER 
CHILDREN 

Malnutrition,  with  tuberculosis  and  syphilis,  is  not  a  part  of  our 
subject.  In  the  sections  on  Malnutrition  in  Infants  and  Children  it 
may  be  thought  that  there  is  repetition  of  what  is  said  under  the  title 
of  the  Delicate  Child.  While  the  management  necessarily  is  along 
the  same  lines,  two  distinct  types  of  children  are  represented.  The 
marasmic  and  malnutrition  infant  or  young  child  may  be  but  tem- 
porarily delicate.  When  the  child  with  simple  malnutrition  recovers, 
he  may  develop  into  as  normal  a  specimen  of  robust  childhood  as 
could  be  desired.  The  delicate  child  as  I  have  endeavored  to  describe 
him  is  inherently  delicate,  and  our  efforts  are  toward  improving  his 
condition,  with  the  hope,  perhaps,  but  with  no  great  assurance,  that 
he  will  some  time  become  a  robust  adult. 

Tardy  malnutrition  is  usually  seen  in  children  of  the  school-age, 
although  it  may  appear  any  time  after  the  third  year.  They  are  de- 
ficient in  weight,  in  resistance  to  disease,  and  in  capacity  for  work; 
they  are  pale,  thin,  tired  children. 


TARDY    MALNUTRITION  101 

Etiology. — Cases  of  tardy  malnutrition  as  well  as  those  of  maras- 
mus and  infantile  malnutrition  are  seen  in  all  the  walks  of  life,  among 
the  wealthy,  the  so-called  middle  class,  and  among  the  poor.  Strange 
as  it  may  seem,  these  cases,  regardless  of  the  station  of  life,  have  two 
causes,  common  to  all,  waste  of  energy  and  defective  feeding.  The 
scion  of  wealth  who  is  overfed  or  badly  fed — given  food  which  is  un- 
suitable, and  allowed  the  promiscuous  use  of  sweets — may  develop 
malnutrition  just  as  effectively  as  the  child  of  the  tenement  who  sub- 
sists on  fried  meats,  grocery  milk,  boxed  breakfast  foods,  and  poorly 
cooked  vegetables. 

The  most  important  factors  in  these  cases  are  overwork — exces- 
sive energy  output,  in  school,  at  work,  or  at  play — and  inadequate  rest. 
The  child  is  active  from  early  morning  until  bedtime  at  7  or  8  o'clock. 
This  entails  waste  of  vitality  and  the  organism  suffers.  Every  child 
until  the  seventh  year  should  have  an  after-dinner  rest,  sleep  if  possible, 
for  one  to  one  and  one-half  hours.  There  should  be  twelve  hours  of 
uninterrupted  sleep  at  night. 

In  all  cases  errors  in  the  daily  life  of  the  patient  will  be  most 
apparent. 

There  is  a  painful  lack  of  knowledge  among  all  classes  as  regards 
the  nourishment  required  by  a  growing  child.  He  is  fed  to  satisfy 
his  appetite,  and  when  this  is  accomplished,  the  parents  believe  that 
their  duty  is  done.  How  far  they  fall  short  of  proper  feeding  is  demon- 
strated daily  in  out-patient  clinics  and  in  private  work.  Poverty  is 
an  occasional  cause  of  bad  feeding  in  New  York  City. 

Treatment. — I  have  repeatedly  seen  children  from  five  to  ten  years 
of  age,  with  marked  malnutrition,  gain  from  3  to  5  pounds  the  first 
month  under  treatment  which  consisted  simply  in  inaugurating  the 
midday  rest  and  in  giving  food  that  they  had  a  right  to  demand, 
properly  prepared  at  definite  intervals.  The  school-child  suffering 
from  malnutrition  should  be  removed  from  school  temporarily,  and 
as  much  outdoor  life  as  possible  should  be  enjoyed  by  him,  regardless 
of  his  station  in  life.  Everything  of  a  strenuous  nature  should  be 
avoided.  He  should  be  put  to  bed  early  and  encouraged  to  sleep  late. 
A  midday  rest  for  one  who  shows  marked  emaciation  and  diminished 
resistance  is  advised. 

Illustrative  Cases. — The  following  is  quite  a  usual  history  of  an  advanced  case 
of  malnutrition  in  a  girl,  seven  years  of  age,  and  the  treatment  is  that  which  we 
usually  employ:  The  mother  brought  the  girl  to  the  out-patient  service  at  the  New 
York  Polyclinic  because  the  child  was  pale,  did  not  grow,  and  was  always  tired — 
too  tired  to  go  to  school,  of  which  she  was  very  fond ;  too  tired  to  play  with  other 
children,  as  had  previously  been  her  custom.  Her  weight  was  41  pounds.  There 
was  loss  of  appetite,  no  food  being  taken  except  on  compulsion.  There  was  no 
evidence  of  congenital  syphilis  or  tuberculosis.  There  was  a  secondary  anemia. 
The  child  slept  in  a  badly  ventilated  room;  she  drank  tea  and  coffee.  Cake, 
pastry,  and  sweets  were  her  regular  diet,  and  because  she  did  not  eat  at  meal- 
times she  was  allowed  to  eat  between  meals  whenever  and  whatever  she  pleased. 
The  following  mode  of  life  and  diet  was  prescribed:  She  was  to  sleep  in  the  front 
room,  known  as  a  sitting-room  or  parlor,  with  a  window  open  at  least  six  inches. 
She  was  given  three  meals  a  day  with  nothing  whatever  between  meals.  The  diet 
consisted  of  red  meat  once  a  day,  two  or  three  soft-boiled  eggs  daily,  one  quart  of 
good  milk  daily  if  it  agreed  (and  it  did  agree).     She  was  to  have  only  natural 


102  THE    PRACTICE    OF    PEDIATRICS 

cereals,  such  as  oatmeal,  cracked  wheat,  and  cornmeal — each  of  which  was  to  be 
cooked  three  hours  the  day  before  it  was  to  be  given.  Baked  or  boiled  potatoes 
and  one  green  vegetable  were  to  form  a  part  of  the  dinner  at  midday.  Stewed  and 
raw  fruits  and  plain  puddings  with  home-made  bread  and  plenty  of  butter  com- 
pleted the  dietary.  She  was  put  to  bed  at  7  o'clock  and  arose  at  7  the  following 
morning.  An  after-dinner  rest  in  a  darkened  room  for  an  hour  was  insisted  upon. 
Before  retiring  she  was  given  a  brine  bath  (p.  780), followed  by  a  brisk  drying  with 
a  rough  towel,  after  which  her  entire  body  was  rubbed  for  ten  minutes  with  olive 
oil.  In  one  month  a  radical  change  had  taken  place.  She  had  gained  4  pounds  in 
weight.  Her  color  was  good.  She  complained  no  more  of  languor  or  fatigue. 
She  was  eager  for  school.  The  improvement  continued,  and  in  ten  weeks  she  made 
a  perfect  recovery.  In  not  every  case  will  results  be  so  prompt  and  satisfactory. 
In  some,  a  longer  time  will  be  required  before  pronounced  results  are  to  be  seen. 
Every  child  suffering  from  malnutrition  of  this  type  cannot  help  being  benefited 
more  or  less  by  such  a  regime. 

A  most  pronounced  case  of  this  type  was  in  a  boy,  eight  years  of  age,  who  pre- 
sented a  most  dilapidated  picture.  He  was  tall  for  his  age,  very  thin,  pale,  habitu- 
ally tired,  and  had  a  well-developed  habit-spasm.  He  was  restless,  active,  and 
played  hard  when  he  was  not  too  tired  to  play.     His  weight  was  59  M  pounds. 

The  living  regime  prescribed  was  as  follows:  He  breakfasted  at  7.30  a.  m.  He 
was  to  remain  in  bed  until  10  o'clock  in  the  morning,  then  up  and  about  at  play  as 
he  wished.  Dinner  at  12.30  was  followed  by  a  rest  of  one  and  one-half  hours. 
Play  was  permitted  without  particular  restraint  until  supper  at  6.30.  Bedtime 
was  7.30  p.  M.  He  improved  rapidly  and  in  one  month  was  permitted  to  arise 
with  the  family.     From  October  12th  to  May  27th  he  gained  in  weight  19)4  pounds. 

I  have  treated  a  great  many  of  these  cases  of  malnutrition  in  older 
children  in  the  same  manner,  by  limiting  the  energy  output,  and  right 
feeding.  A  gain  of  from  2  to  6  pounds  a  month  for  the  first  month  or 
two  is  the  usual  result  of  the  treatment.  At  the  same  time  there  is  a 
radical  change  in  the  child's  mental  attitude  and  general  appearance. 

Tonics. — The  tincture  of  nux  vomica,  4  drops  in  water  before  meals, 
is  sometimes  given  to  children  whose  appetite  is  defective.  One  grain 
of  the  citrate  of  iron  and  quinin  in  1  dram  of  equal  parts  of  sherry  wine 
and  water  may  be  substituted.  If  there  is  secondary  anemia  and  a 
defective  nerve  resistance,  the  following  prescription  is  given,  inter- 
rupted by  five  days  free  from  medication. 

For  a  child  five  to  ten  years  of  age: 

I^    Liq.  potassii  arsenitis it^lxiv 

Liq.  ferri  albuminati 3iv 

Syr.  hypophosphitum  (calcis  et  sodae) 5iij 

Aqua; q.  s.  ad   gvj 

M.  ft.  Sig. — One  teaspoonful  after  meals  in  water. 

During  the  five  days  without  the  medication  cod-liver  oil  may  be 
given. 

Constipation. — If  constipation  is  present,  olive  oil  may  be  given 
internally,  2  or  3  drams  after  meals.  If  the  oil  is  not  well  taken,  or  if  it 
disagrees  in  any  way,  its  use  should  be  discontinued.  Liquid  albolene 
(aromatic),  in  3^^  to  1  ounce  dosage  at  bedtime,  answers  well  in  many. 
The  dosage  may  be  gradually  reduced  and  later  discontinued. 

Feeding  After  the  First  Year 
general  properties  of  foods 

Substances  used  as  foods,  regardless  of  the  animal  which  they  may 
nourish,  possess  the  common  property  of  being  composed  of  fat,  pro- 


GENERAL    PROPERTIES    OF    FOODS  103 

teids,  carbohydrates,  mineral  substances,  and  water,  in  varying  propor- 
tions. The  purposes  that  these  serve  in  the  animal  economy  are  essen- 
tially the  same  in  all  forms  of  animal  life.  In  order  to  determine  the 
food-value  of  any  substance,  a  chemical  analysis  which  shows  the 
quantities  of  these  nutritional  elements  is  required.  It  will  be  found 
that  foods  varying  widely  in  appearance  and  physical  properties  are 
still  similar  in  that  they  are  composed  of  the  same  food  elements,  al- 
though in  different  proportions. 

Foods  used  to  sustain  animal  life  in  any  form  must  contain  the 
ingredients  needed,  and  these  must  be  present  in  a  form  suited  to  the 
particular  kind  of  animal  to  be  fed,  whether  it  is  man  or  one  of  the 
lower  animals. 

The  Ingredients  of  Foods. — In  the  individual  foods  the  nutritional 
elements  exist  in  widely  differing  forms.  Fat  may  be  supplied  in  meat, 
cream  or  milk,  butter,  oleomargarin  or  butterine,  lard,  olive  oil,  cod- 
liver  oil,  linseed  oil,  cottonseed  oil,  etc.  Carbohydrates  may  be 
furnished  in  the  form  of  cane-sugar,  milk-sugar,  maltose,  and  dextrose 
— soluble  products  derived  from  starch,  corn-starch,  wheat  or  other 
flour,  oatmeal,  rice,  hominy,  bread,  potatoes,  etc.  Proteids  are  secured 
in  the  form  of  lean  beef,  lamb,  or  pork,  chicken,  fish,  the  gluten  of  such 
cereals  as  wheat  and  oats,  and  also  in  large  quantities  from  peas,  beans, 
lentils,  and  other  legumes,  from  the  curd  of  milk,  and  from  eggs.  The 
mineral  substances  of  food  are  found  combined  with  the  other  ingredi- 
ents in  the  form  of  lime,  phosphates,  magnesium,  etc. 

The  Function  of  the  Food  Elements. — The  proteids  of  the  food  are 
used  to  form  the  bodily  structures  and  to  replace  tissue  consumed  by 
the  vital  processes  and  excreted  as  urea.  The  vital  processes,  such  as 
the  circulation  of  the  blood,  respiration,  and  contractions  of  the 
muscles,  call  for  energy,  and  this,  together  with  bodily  heat,  must  be 
supplied  by  the  fats  and  carbohydrates.  The  mineral  substances  are 
used  in  the  formation  of  bone  and  teeth,  while  the  water  serves  to 
dissolve  the  food  elements  after  they  have  been  digested  and  to  carry 
oft  waste  products. 

The  Advantage  of  a  Knowledge  of  the  Composition  of  Foods. — 
Inasmuch  as  each  food  element  has  a  special  function  to  perform,  and 
since  growth  is  impossible  without  a  sufficient  supply  of  these  nutri- 
tional elements,  particularly  the  proteid,  it  is  essential  to  know  within 
reasonable  limits  the  composition  of  a  food,  because  if  the  elements  are 
not  present  in  proper  proportions,  disappointing  results  may  be  obtained 
from  their  use,  which  will  appear  inexplicable,  but  which  will  readily 
be  accounted  for  if  we  know  what  element  of  the  food  is  at  fault.  For 
these  reasons  it  is  coming  to  be  the  practice,  in  infant-feeding  especially, 
to  speak  of  the  percentage  composition  of  the  milk-foods  as,  for  ex- 
ample, a  food  containing  4  per  cent,  fat,  7  per  cent,  carbohydrates,  2 
per  cent,  proteids,  and  0.35  per  cent,  mineral  substances.  Knowing 
from  wide  experience  the  percentages  of  these  ingredients  generally 
needed  in  a  food  if  it  is  properly  to  nourish  a  child,  the  physician  can 
determine  in  an  instant  whether  an  infant  is  having  a  food  of  suitable 


104  THE    PRACTICE    OF    PEDIATRICS 

nutritive  value,  by  comparing  its  known  composition  with  that  estab- 
lished, by  experiment,  as  requisite. 

The  Selection  of  Food. — In  a  review  of  analyses  of  foods  many 
substances  will  be  noticed  which,  according  to  their  chemical  compo- 
sition, have  the  same  food-value,  but  which  common  sense  tells  us  are 
not  interchangeable.  For  instance,  no  one  would  attempt  to  feed  to  a 
human  being  cracked  oats  unless  thoroughly  cooked,  but  he  would  give 
them  raw  to  the"  lower  animals.  They  will  nourish  a  man  or  the  animal 
equally  well,  but  for  man  they  must  be  prepared,  while  the  horse,  for 
example,  can  utilize  them  in  their  original  state.  This  illustrates  the 
importance  of  adapting  food  to  the  consumer.  Often  the  question  in 
feeding  is  not  so  much.  Is  the  food  nutritious?  as.  Can  the  patient 
assimilate  it?  Oftentimes  success  in  infant-feeding  lies  in  the  physi- 
cian's ability  to  discover  a  form  of  fat,  carbohydrate,  and  proteid  which 
the  infant  can  assimilate.  In  the  following  pages  feeding  measures  for 
temporary  use  will  be  found  which  may  not  conform  to  what  some  may 
consider  strictly  scientific  principles;  yet  they  often  give  brilliant  re- 
sults. Looking  a  little  below  the  surface,  it  will  be  found  that  the 
measures  suggested  are  not  unscientific,  and  that  the  results  are  due  to 
applying  the  fixed  principles  of  nutrition  in  perhaps  novel  or  unusual 
ways.  It  is  usually  best  to  follow  the  most  direct  route  to  any  place, 
but  when  this  is  badly  blocked  it  is  better  to  go  another  way,  if  there  is 
one,  rather  than  not  to  arrive  at  one's  destination. 

General  Properties  of  Milks. — When  most  young  animals  are 
born,  their  digestive  organs  are  in  a  more  or  less  embryonic  condition, 
and  it  is  several  months  before  they  entirely  outgrow  this  state.  Dur- 
ing this  period  the  nourishment  is  supplied  by  the  mother  through  her 
mammary  glands,  first  as  colostrum  and  later  as  milk.  When  these 
secretions  are  analyzed  they  are  found  to  consist  of  fat,  carbohydrates, 
proteids,  mineral  substances,  and  water,  and  in  this  respect  they  do  not 
differ  from  other  foods.  But  the  elements  exist  in  the  secretion  in 
peculiar  forms,  and  the  natural  inference  is  that  in  some  way  they  must 
be  particularly  suited  to  animals  whose  digestive  organs  are  still 
undeveloped. 

The  digestive  secretions  of  the  stomachs  of  all  known  animals  con- 
tain pepsin  and  hydrochloric  acid.  In  the  very  young  these  secretions 
are  feeble,  but  as  development  proceeds  they  are  much  more  abundant. 
To  understand  milk  as  a  food  one  must  know  the  effect  upon  it  of  pepsin 
and  acid.  When  pepsin  is  added  to  tepid  cow's  milk  it  causes  the  milk 
to  gelatinize,  with  the  formation  of  curd  or  junket.  If  the  milk  is 
slightly  acidified  or  soured,  the  curd  formed  is  dense  and  solid  and  more 
difficult  of  digestion.  When  the  milk  of  the  cow  or  the  ass  or  human 
milk  is  treated  with  pepsin  and  acid  in  exactly  the  same  way,  curds 
totally  different  are  formed,  and  as  the  human  digestive  organs  are  differ- 
ent from  those  of  the  cow  or  the  ass,  it  is  believed  that  these  differences 
in  the  digestive  properties  of  milks  are  for  the  purposes  of  making  the 
milks  suitable  for  the  different  kinds  of  digestive  tracts.  Milks  may  be 
regarded  as  special  forms  of  food  which  require  greater  digestive  effort 


DIET    FROM    THE    FIRST    TO    THE    SIXTH    YEAR  105 

as  the  digestive  secretions  of  the  stomach  become  stronger,  and  thus 
soHd  food  is  furnished  to  the  developing  stomach.  It  is  that  portion  of 
the  proteid  of  the  milk  called  "casein"  that  is  changed  into  a  solid  by 
the  pepsin  of  the  stomach.  The  term  casein,  however,  has  been  loosely 
applied  to  all  the  proteids  of  all  milks.  The  caseins  of  all  milks  are  not 
alike  in  their  digestive  properties.  Therefore,  the  mistake  of  so  con- 
sidering them  should  be  guarded  against.  A  consideration  of  such  a 
modification  and  adaptation  of  cow's  milk  as  will  make  it  acceptable  to 
the  infant's  digestive  possibilities  will  be  found  in  the  chapter  dealing 
with  Substitute  Feeding. 

DIET  FROM  THE  FIRST  TO  THE  SIXTH  YEAR 

At  the  completion  of  the  twelfth  month  the  average  well-regulated 
baby  should  be  weaned  and  given  other  nourishment.  If  bottle-fed, 
he  should  receive  more  than  the  milk  and  cereals,  with  which  most 
children  are  fed.  The  food  suitable  for  the  second  year  of  life  and  the 
method  of  its  preparation  and  administration  are  subjects  concerning 
which  the  masses  are  most  profoundly  ignorant.  A  few  children  at  this 
period  of  life  are  underfed,  but  the  great  majority  are  overfed  and  care- 
lessly given,  at  improper  intervals,  unsuitable  food,  indifferently  pre- 
pared. Summer  diarrhea  finds  its  greatest  number  of  victims  among 
those  children  over  twelve  months  of  age  who  have  been  carelessly  fed. 

The  Second  Summer. — The  dreaded  ''second  summer"  robs  many 
homes  because  of  ignorant  or  careless  parents.  The  second  summer, 
approached  properly,  is  hardly  more  dangerous  than  any  other  summer 
during  the  early  years  of  a  child's  life.  It  is  almost  a  universal  custom, 
when  the  child  is  weaned  or  given  something  other  than  a  milk  diet,  to 
allow  him  "tastes"  from  the  table.  Very  often  these  tastes  comprise 
the  entire  dietary  of  the  adult.  Milk  is  oftentimes  the  only  suitable 
article  of  diet  that  is  given.  Eventually,  not  only  is  the  other  food 
selected  unsuitable,  but  it  is  given  irregularly,  and  supplemented  by 
crackers  kept  on  hand  for  use  between  meals.  During  the  hot  months 
the  gastro-intestinal  tract  is  less  able  to  bear  such  abuse  and  the  child 
becomes  ill. 

Feeding  After  the  First  Year. — Usually  when  the  twelfth  month 
is  completed  I  give  the  mother  a  diet  schedule,  with  instructions  to 
begin  gradually  with  the  articles  allowed,  in  order  to  test  the  child's 
ability  to  digest  them.  Every  new  article  of  food  should  be  carefully 
prepared  and  given  at  first  in  very  small  quantities.  All  meals  are  to 
be  given  regularly,  with  nothing  between  meals.  With  many  chil- 
dren this  expansion  of  the  diet-list  is  attended  with  considerable  diffi- 
culty. They  are  thoroughly  satisfied  with  milk,  and  refuse  all  other 
forms  of  nourishment.  In  such  cases  time  and  patience  are  necessary 
at  the  feeding-time.  The  more  solid  articles  of  diet  should  be  given 
first  and  the  milk  kept  in  the  background. 

Among  the  underfed  seen  at  this  period  of  life  are  those  who  were 
nursed  too  long  or  those  who  were  kept  too  long  upon  an  exclusive  milk 


106  THE    PRACTICE    OF    PEDIATRICS 

diet.  A  great  majority  of  the  cases  of  malnutrition  of  the  second  year 
are  seen  in  the  exclusively  milk  fed.  These  children  are  pale,  soft, 
flabby,  and  badly  nourished. 

The  following  is  a  diet  schedule  which  I  have  employed  for  several 
years.  Each  mother  is  instructed  to  select,  from  the  foods  allowed,  a 
suitable  meal: 

From  the  twelfth  to  the  fifteenth  month;  five  meals  daily: 

7  A.  M.:  Oatmeal,  barley  or  wheat  jelly,  one  to  two  tablespoonfuls 
in  8  ounces  of  milk.  (The  jelly  is  made  by  cooking  the  cereal  for  four 
hours  the  day  before  it  is  wanted  and  straining  through  a  colander.) 
Stale  bread  and  butter  or  zwieback  and  butter. 

9  A.  M.:  The  juice  of  one  orange. 

11  A.  M.:  Scraped  rare  beef,  one  to  three  teaspoonfuls,  mixed  with 
an  equal  quantity  of  bread  and  moistened  with  beef-juice.  Or  a  soft- 
boiled  egg  mixed  with  stale  bread-crumbs;  a  piece  of  zwieback  and  a 
half-pint  of  milk. 

(Scraped  beef  is  best  obtained  from  round  steak,  cut  thick  and 
broiled  over  a  brisk  fire  sufficiently  to  sear  the  outside.  The  steak  is 
then  split  with  a  sharp  knife  and  the  pulp  scraped  from  the  fiber.) 

3  p.  M.:  Beef,  chicken,  or  mutton  broth,  with  rice  or  stale  bread 
broken  into  the  broth.  Stale  bread  and  butter  or  zwieback  and  butter, 
apple-sauce  and  prune  pulp;  corn-starch  pudding,  junket. 

6  p.  M.:  Two  tablespoonfuls  of  cereal  jelly  in  8  ounces  of  milk;  a 
piece  of  zwieback.  Stale  bread  and  butter  or  Huntley  and  Palmer 
breakfast  biscuit. 

10  p.  M. :  A  tablespoonful  of  cereal  jelly  in  8  ounces  of  milk. 

From  the  fifteenth  to  the  eighteenth  month;  four  meals  daily: 

7  A.  M. :  Oatmeal,  hominy,  cornmeal,  each  cooked  four  hours  the  day 
before  they  are  used.  When  the  cooking  is  completed,  the  cereal 
should  be  of  the  consistence  of  a  thin  paste.  This  is  strained  through 
a  colander,  which  upon  cooling  will  form  a  mass  of  jelly-like  consistence. 
Of  this  give  two  or  three  tablespoonfuls,  served  with  milk  and  sugar,  or 
butter  and  sugar,  or  butter  and  Bait.  Eight  to  ten  ounces  of  milk  as  a 
drink.     Zwieback  or  toast. 

9  A.  M. :  The  juice  of  one  orange. 

11  A.  M.:  A  soft-boiled  egg  mixed  with  stale  bread-crumbs,  or  one 
tablespoonful  of  scraped  beef  (p.  70),  mixed  with  stale  bread-crumbs 
and  moistened  with  beef-juice,  or  a  tablespoonful  of  minced  white  meat 
of  chicken.  A  drink  of  milk.  Zwieback  or  bran  biscuit,  or  stale  bread 
and  butter. 

3  p.  M.:  Mutton,  chicken,  or  beef  broth,  with  rice  or  with  stale 
bread  broken  in  the  broth.  Custard,  corn-starch,  plain  rice  pudding, 
junket,  stewed  prunes,  baked  apple,  or  apple-sauce. 

6  p.  M.:  Farina,  cream  of  wheat,  wheatena  (cooked  two  hours). 
Give  from  one  to  three  tablespoonfuls,  served  with  milk  and  sugar,  or 
butter  and  sugar,  or  salt  and  butter.  Drink  of  milk.  Zwieback  or 
stale  bread  and  butter. 


DIET    FROM    THE    FIRST    TO    THE    SIXTH    TEAR  107 

From  the  eighteenth  to  the  twenty-fourth  month;  jour  meals  daily: 

7  A.  M.:  Cornmeal,  oatmeal,  hominy  (prepared  as  in  the  above 
schedule).  Serve  with  butter  and  sugar,  or  milk  and  sugar,  or  butter 
and  salt.  A  soft-boiled  egg  every  two  or  three  days.  Hashed  chicken 
on  toast  occasionally.  A  drink  of  milk.  Bran  biscuit  and  butter  or 
stale  bread  and  butter. 
.    9  A.  M. :  The  juice  of  one  orange. 

11  A.  M. :  Rare  beef,  minced  or  scraped;  the  heart  of  a  lamb  chop, 
finely  cut;  minced  chicken.  Spinach,  asparagus  tips,  squash,  strained 
stewed  tomatoes,  stewed  carrots,  mashed  cauliflower.  Baked  apple  or 
apple-sauce.     Stale  bread  and  butter. 

After  the  twenty-first  month  baked  potatoes  and  well-cooked 
string-beans  may  be  given. 

3  p.  M.:  Chicken,  beef,  or  mutton  broth,  with  rice  or  with  stale 
bread  broken  into  the  broth.  Custard,  corn-starch,  or  plain  rice  pud- 
ding, junket,  stewed  prunes.  Bran  biscuit  and  butter  or  stale  bread 
and  butter. 

6  p.  M,:  Farina,  cream  of  wheat,  wheatena  (each  cooked  two  hours). 
Give  from  one  to  three  tablespoonfuls,  served  with  milk  and  sugar, 
or  butter  and  sugar,  or  butter  and  salt.  Drink  of  milk.  Zwieback  or 
stale  bread  and  butter. 

After  the  eighteenth  month  a  large  number  of  children  will  have  a 
better  appetite  and  thrive  more  satisfactorily  on  three  full  meals  a  day. 
The  breakfast  is  advised  at  7.30  a.  m.  and  the  dinner  at  12  o'clock. 
At  3  p.  M.  or  3.30  p.  m.  a  cup  of  broth  and  a  cracker  or  toast  and  a  drink 
of  milk  may  be  given. 
From  the  second  to  the  third  year;  three  meals  daily: 

Breakfast:  7  to  8  o'clock.  Oatmeal,  cornmeal,  hominy,  cracked 
wheat  (each  cooked  four  hours  the  day  before  they  are  used),  served 
with  milk  and  sugar  or  butter  and  sugar.  A  soft-boiled  egg,  or 
minced  chicken.  vStale  bread  and  butter.  Bran  biscuit  and  butter. 
A  drink  of  milk. 

At  10  o'clock  the  juice  of  one  orange  may  be  given. 

Dinner:  12  o'clock.  Strained  soups  and  broths,  rare  beefsteak, 
Tare  roast  beef,  poultry,  fish.  Baked  potato,  peas,  string-beans,  squash, 
mashed  cauliflower,  mashed  peas,  strained  stewed  tomatoes,  stewed 
carrots,  spinach,  asparagus  tips.  Bread  and  butter.  For  dessert: 
plain  rice  pudding,  plain  bread  pudding,  stewed  prunes,  baked  or 
stewed  apple,  junket,  custard,  corn-starch,  or  gelatine  pudding. 

Supper:  5.30  to  6  o'clock.  Farina,  cream  of  wheat,  wheatena 
(each  cooked  two  hours).  Give  from  one  to  three  tablespoonfuls 
served  with  milk  and  sugar,  or  butter  and  sugar,  or  butter  and  salt. 
Drink  of  milk.  Zwieback  or  stale  bread  and  butter.  Twice  a  week 
custard,  corn-starch,  or  junket  may  be  given,  or  a  tablespoonful  of 
plain  vanilla  ice-cream. 

As  a  rule,  three  meals  answer  best  at  this  period.  With  three 
meals  a  child  has  a  better  appetite  and  much  better  digestion,  and 
consequently  thrives  far  better  than  one  whose  stomach  is  kept  con- 


108  THE    PRACTICE    OF    PEDIATRICS 

stantly  at  work.  Some  children,  however,  will  require  a  luncheon 
at  3  or  3.30  p.  M,,  and  will  not  do  well  without  it.  This  is  apt  to  be  the 
case  with  delicate  children,  particularly  those  under  two  and  one-half 
years  of  age.  If  food  is  necessary  at  this  hour,  a  glass  of  milk  and  a 
Graham  biscuit  or  a  cup  of  broth  and  zwieback  will  answer  every  pur- 
pose. Instead  of  the  afternoon  meal,  the  child  may  relish  a  scraped 
raw  apple  or  a  pear.  Fruit  at  this  time  is  particularly  to  be  advised 
if  there  is  constipation.  Children  recovering  from  serious  illness 
will  require  more  frequent  feeding. 
From  the  third  to  the  sixth  year: 

Breakfast:  Cracked  wheat,  cornmeal,  hominy,  oatmeal  (each 
cooked  four  hours  the  day  before  they  are  used).  These  may  be 
served  with  milk  and  sugar,  or  butter  and  sugar,  or  butter  and  salt. 
A  soft-boiled  egg,  omelet,  scrambled  egg.  Bread  and  butter,  bran 
biscuit  and  butter.     A  glass  of  milk. 

Dinner:  Plain  soups,  rare  roast  beef,  beefsteak,  poultry,  fish, 
creamed  or  baked  potatoes.  Peas,  string-beans,  strained  stewed  toma- 
toes, stewed  carrots,  squash,  boiled  onions,  mashed  cauliflower, 
spinach,  asparagus  tips,  bread  and  butter.  For  dessert:  Rice  pud- 
ding, plain  bread  pudding,  custard,  tapioca  pudding,  gelatine  pudding, 
stewed  prunes,  stewed  apples,  baked  apples,  raw  apples,  pears,  and 
cherries. 

Supper:  Farina,  cream  of  wheat,  wheatena  (each  cooked  two  hours) . 
Give  from  two  to  three  tablespoonfuls,  served  with  milk  and  sugar,  or 
butter  and  sugar,  or  butter  and  salt.  Zwieback  or  stale  bread  and 
butter.  Bread  and  milk.  Milk-toast.  Scrambled  eggs  twice  a  week. 
Custard  or  corn-starch  each  once  a  week;  ice-cream  once  a  week. 
Bread  and  butter.     A  glass  of  milk. 

When  the  child  has  eggs  for  breakfast,  they  should  not  be  repeated 
in  any  form  for  supper.  Red  meat  should  be  given  but  three  times  a 
week.  When  the  child  has  a  chop  for  breakfast,  he  should  have 
poultry  or  fish  for  dinner.  At  this  age  of  great  activity  and  rapid 
growth  the  child  will  often  demand  food  between  dinner  and  supper. 
Carefully  selected  fruit,  such  as  an  apple,  a  pear,  or  a  peach,  may  be 
given  at  this  time,  supplemented  by  a  Graham  cracker  or  two,  or  by 
stale  bread  and  butter,  if  it  is  found  that  their  use  does  not  interfere 
with  the  evening  meal. 

DIET  AFTER  THE  SIXTH  YEAR 

When  the  normal  child  has  passed  the  sixth  year  the  diet  may  be 
considerably  expanded,  approximating  to  that  of  the  adult  in  variety ; 
certain  restrictions,  however,  are  to  be  borne  in  mind.  Fried  foods 
should  not  be  given;  highly  seasoned  dishes,  such  as  pie,  rich  puddings, 
gravies,  and  sauces,  are  to  be  avoided.  Salads  with  plain  dressing  may 
now  be  given.  Wine  and  beer,  coffee,  and  tea  should  never  be  given 
to  children  as  a  beverage.  A  point  to  be  kept  in  mind  in  feeding  chil- 
dren of  this  age,  as  well  as  those  who  are  younger,  is  the  proper  cooking 


DIET    DURING    ILLNESS  109 

of  vegetables.     Everything  in  the  Une  of  green  vegetables  should  be 
cooked  until  it  can  readily  be  mashed  with  a  fork. 

DIET  DURING  ILLNESS 

The  digestive  capacity  of  every  child  is  diminished  during  illness, 
the  extent  depending  largely  upon  the  age  of  the  child  and  the  severity 
of  the  disease.  The  younger  the  child,  the  greater  the  incapacity. 
This  is  fairly  constant  with  all  the  ailments  of  childhood,  including,  of 
course,  those  which  directly  affect  the  gastro-enteric  tract. 

Reduction  in  Food  Strength. — In  a  moderately  severe  bronchitis, 
with  a  degree  or  two  of  fever,  the  digestive  capacity  is  slightly  diminished 
and  a  25  per  cent,  reduction  in  the  strength  of  the  food  will  answer. 
During  the  critical  stage  of  a  lobar  pneumonia  the  digestive  powers 
are  held  in  abeyance  and  predigested  foods  and  alcohol  must  sustain 
the  patient.  During  an  attack  of  measles,  scarlet  fever,  broncho- 
pneumonia, or  diphtheria  in  bottle-fed  infants,  at  the  height  of  the 
disease,  it  is  my  custom  to  reduce  the  strength  of  the  food  one-half  by 
the  addition  of  water,  to  make  up  for  the  quantity  removed.  For  ail- 
ments of  lesser  severity,  such  as  bronchitis,  with  a  temperature  of  100° 
to  101°F.,  or  chicken-pox,  or  mild  measles,  I  reduce  the  strength  of  the 
food  from  one-fourth  to  one-third.  In  the  event  of  any  mild  ail- 
ment or  injury  which  confines  a  child  to  his  bed,  the  food  strength 
should  be  cut  down,  for  inactivity  as  well  as  disease  lessens  the  digest- 
ive capacity. 

Among  nurslings  and  the  bottle-fed  these  precautions  are  particu- 
larly necessary.  A  child  with  fever  is  apt  to  be  thirsty  and  to  take 
more  fluid  than  in  health.  This  is  frequently  the  case  during  summer 
diarrhea.  In  order  to  prevent  taking  too  much  food,  I  not  only  order 
that  the  milk  be  diluted  for  the  bottle-fed,  but  I  instruct  the  mothers 
of  nurslings  to  give  a  drink  of  water  immediately  before  each  nursing 
and  between  nursings,  and  then  to  allow  the  child  to  nurse  only  one- 
half  or  two-thirds  the  usual  time.  For  the  bottle-fed,  one-half  to  one- 
third  of  the  contents  of  each  bottle  is  removed  and  the  quantity  re- 
placed by  boiled  water,  so  that  the  amount  of  fluid  given  remains  the 
same. 

If  a  child  is  a  "runabout,"  over  two  years  of  age,  he  is  given  broths 
and  thin  gruel — one-half  milk  and  one-half  gruel.  By  carefully  watching 
the  stools,  thus  fitting  the  food  to  the  child's  capacity,  we  will  avoid 
grave  intestinal  complications  which,  during  the  summer,  often  prove 
to  be  more  serious  than  the  original  ailment.  In  the  acute  gastro-enteric 
troubles  and  in  typhoid  fever,  all  milk  must  be  discontinued. 

The  dietetic  management  of  the  acute  intestinal  diseases  and 
typhoid  fever  is  referred  to  in  detail  under  the  respective  headings. 

The  Art  of  Feeding  in  Illness. — Not  only  is  food  oftentimes  taken 
in  insufficient  quantity  in  illness,  but  in  many  cases  it  is  absolutely 
refused.  In  other  cases,  during  coma  and  asthenic  states,  swallowing 
is  impossible.     In  delirium  and  in  conditions  of  collapse  nourishment 


110  THE    PRACTICE    OF    PEDIATRICS 

must  be  given,  and  when  this  is  impossible  by  the  natural  method,  we 
have,  as  temporary  substitutes,  gavage,  oil  inunctions,  and  rectal  feed- 
ing— all  referred  to  elsewhere. 

Forcing  the  child  to  take  nourishment  by  the  mouth  is  rarely  neces- 
sary. Coaxing  and  bribing  ordinarily  succeed  far  better.  For  a  child 
from  three  to  five  years  of  age  a  bright  new  penny  possesses  much  per- 
suasive power..  The  child  will  usually  take  food  better  from  one  to 
whom  he  is  accustomed,  like  the  mother  or  nursery  maid.  The 
trained  nurse  should  understand  that  while  she  is  unacquainted  with 
the  patient,  the  simpler  requirements  of  the  child  are  to  be  looked 
after  by  others  to  whom  the  patient  is  accustomed. 

The  nourishment  should  be  as  palatable  as  possible  and  served 
in  bowls,  cups,  or  plates  that  are  attractive  to  the  patient,  because  of 
color,  pictures,  or  peculiarities  of  shape.  Junket,  flavored  with  vanilla, 
served  cold,  is  a  favorite  food  for  sick  children  of  the  "runabout"  age. 
Frozen  custard  and  home-made  ice-cream,  made  with  one-third  cream 
and  two-thirds  milk,  will  usually  be  well  taken.  Toast,  dry  bread,  and 
crackers  made  in  peculiar  shapes  are  attractive  to  the  child.  In  not  a 
few  cases  I  have  succeeded  in  feeding  satisfactorily  children  two  or 
three  years  old,  when  several  other  schemes  had  failed,  by  allowing 
the  temporary  return  to  the  bottle,  from  which  they  had  been  weaned 
for  a  year  or  so. 

In  these  difficult  feeding  cases  the  child's  peculiarities  and  wishes 
must  be  studied.  Children  in  illness  require  water.  Oftentimes  they 
take  it  in  insufficient  quantities.  Those  who  refuse  plain  water  will 
often  take  ginger  ale,  sarsaparilla,  or  vichy.  In  the  event  of  these 
drinks  being  well  taken,  they  may  be  given  freely.  In  the  acute  in- 
fectious diseases,  which  include  pneumonia,  free  water-drinking  is  a- 
therapeutic  measure  of  no  mean  value. 

COMMON  ERRORS  IN  FEEDING 

In  the  care  of  the  bottle-fed  the  most  frequent  error  is  overfeeding^. 
or  the  use  of  a  stronger  mixture  than  the  child  is  able  to  digest.  Par- 
ticularly is  this  apt  to  be  the  case  at  the  commencement  of  bottle-feed- 
ing. The  amount  is  usually  too  large  and  the  intervals  between  the 
feedings  are  almost  invariably  too  short.  Children  of  the  same  age 
cannot  all  he  fed  alike.  Artificially  fed  babies  of  equal  health  and 
vigor,  but  of  considerably  varied  size  and  weight,  will  require  food 
of  approximately  the  same  strength,  and  the  same  intervals  between 
feedings;  but  the  larger  the  child,  the  greater  the  quantity  of  food 
required.  Thus,  the  quantity  given  at  one  feeding  for  a  child  weigh- 
ing 13  pounds  at  the  sixth  month  will  not  be  sufficient  for  a  child  of  the 
same  age  weighing  16  pounds. 

The  quantity  of  food  for  each  feeding  for  an  average  baby  weighings 
15  pounds  at  six  months  is  about  6  ounces,  and  this  quantity  should  be 
diminished  3^^  ounce  for  every  pound  under  this  weight  until  the  total 
quantity  is  reduced  to  4  ounces;  and  for  every  pound  over  15,  3^^ 
ounce  should  be  added  to  each  feeding  until  the  total  is  increased  to  9* 


SCURVY  (scorbutus)  111 

ounces.  The  number  of  feedings  in  twenty-four  hours  should  be  the 
same  for  all  young  children  of  the  same  age.  In  the  table  of  food  for- 
mulas given  on  p.  70  only  the  average  child  of  average  weight  is  con- 
sidered. 

AGE  OF  CHILD,  SIX  MONTHS 

Weight  of  Child  Quantity  for  Each  Feeding 

1 1  pounds 4      ounces 

12  pounds 43^  ounces 

13  pounds 5      ounces 

14  pounds 5}4  ounces 

15  pounds 6      ounces 

16  pounds 6K  ounces 

17  pounds 7      ounces 

18  pounds 7}4  ounces 

19  pounds 8      ounces 

20  pounds 8}4  ounces 

21  pounds 9      ounces 

Keeping  the  child  on  an  exclusive  milk  diet  until  the  twelfth  month 
or  later  is  a  not  infrequent  error.  As  a  rule,  starch  in  some  form 
may  be  added  to  the  food  at  the  seventh  month,  and  should  always 
be  added  as  early  as  the  ninth  month.  The  giving  of  food  other 
than  well-cooked  cereals  and  milk  before  the  twelfth  month  is  a 
mistake  made  in  many  households,  and  a  common  error  from  the 
twelfth  month  to  the  third  year  is  to  allow  the  child 's  diet  to  consist 
largely  of  milk  and  insufficiently  cooked  cereals.  Crackers  and 
milk,  bread  and  milk,  cake,  and  fancy  crackers,  often  constitute 
the  only  articles  of  diet  during  this  very  important  period  of  growth. 
The  fact  that  a  high  proteid  food  is  as  necessary  for  proper  develop- 
ment now  as  at  bottle  age,  is  overlooked.  During  early  infancy 
milk  is  invaluable,  but  it  is  not  sufficient  for  the  demands  of  older 
childhood.  Milk,  eggs,  meat,  and  cereals,  such  as  oatmeal,  rich  in 
proteid,  are  absolutely  necessary  to  normal  growth. 

Irregularity  in  feeding  is  another  frequent  error.  The  child  should 
have  his  meals  "on  the  minute,"  at  the  same  time  every  day.  The 
lack  of  observance  of  this  rule  will  surely  result  in  loss  of  appetite  and 
indigestion.  Indiscriminate  eating  between  meals  of  bread  and  butter, 
pastry,  or  confectionery,  if  persistently  practised,  will  surely  be  followed 
by  indigestion  and  malnutrition. 

Forcing  or  coaxing  a  child  to  eat  is  a  practice  always  to  be 
avoided.  If  suitable  food  is  given  at  definite  well-ordered  intervals, 
a  normal  child  will  be  hungry  at  those  intervals.  If  he  does  not  eat, 
something  is  wrong,  and  it  is  our  duty  to  discover  the  cause  of  his 
loss  of  appetite. 

SCURVY  (SCORBUTUS) 

Scurvy  in  infants  was  first  described  by  Glisson  in  1651.  It  was 
not  well  recognized,  however,  until  Moller  described  it  again  in  1859, 
viewing  the  disease  as  an  acute  type  of  rachitis.  Ingelev,  of  Sweden, 
recognized  a  case  of  apparent  infantile  scorbutus  in  1873,  and  in  the 
period  1879-82  Cheadle  reported  several  cases.     In  1883  Sir  Thomas 


112  THE    PRACTICE    OF    PEDIATRICS 

Barlow  was  able  to  give  a  clear  demonstration  of  the  clinical  features 
and  pathology  of  this  disease,  and  thenceforth  reports  of  its  occurrence 
were  frequent.  Infantile  scurvy,  or  MoUer-Barlow's  disease,  is  a  very 
definite  affection,  and,  although  the  term  "scurvy-rickets"  still  persists, 
this  serves  only  to  emphasize  the  frequent  coexistence  in  a  patient  of 
the  two  essentially  distinct  conditions. 

Pathology. — The  two  leading  features  in  the  morbid  anatomy 
of  scurvy  are  multiple  hemorrhages  and  rarefaction  of  bone.  Whether 
the  atrophy  in  the  bone  is,  or  is  not,  a  result  of  the  intra-osseous  ex- 
travasations, seems  uncertain.  It  is,  however,  believed  that  the  rare- 
faction may  occur  primarily,  independent  of  the  hemorrhagic  lesions. 
Although  in  some  instances  hematuria  is  the  only  prominent  symptom, 
bleeding  is  usually  not  confined  to  any  particular  site,  but  may  occur 
under  the  periosteum,  in  the  bone-marrow,  under  the  skin,  under  the 
membrane  lining  the  serous  cavities,  or  from  the  mucous  surfaces.  In 
the  bones,  the  most  severe  lesions  are  found  in  the  neighborhood  of  the 
epiphyses.  The  lymphoid  marrow  cells  and  the  osteoblasts  are  dimin- 
ished in  number,  and  there  is  increased  porosity  of  the  cancellous  tissue. 
Fractures  of  the  ends  of  the  long  bones  are  exceedingly  common.  In 
several  cases  I  have  seen  separation  of  the  epiphyses.  In  one  case 
there  were  four  so-called  fractures — two  at  the  shoulder-joint  in  each 
humerus,  and  two  at  the  hips  in  each  femur.  Beneath  the  periosteum 
are  extensive  extravasations  of  blood,  which  frequently  become  organ- 
ized into  firm  layers  of  clot.  In  rare  instances  hemorrhages  occur 
within  the  joints. 

In  scurvy  there  are  probably  alterations  in  the  capillary  walls  which 
permit  the  diapedesis  of  the  red  cells.  Wright  has  recently  shown  that 
in  this  disease  the  alkalinity  of  the  blood  may  be  reduced  to  a  point  as 
low  as  ^^^00  of  the  normal,  and  he  regards  scurvy  as  a  form  of  acid 
intoxication. 

Autopsy  upon  a  child  that  died  from  scurvy  revealed  extensive 
separation  of  the  periosteum  from  all  the  long  bones,  from  which  mas- 
sive clots  of  blood  were  removed. 

Age. — The  age  incidence  is  significant.  In  a  large  number  of  cases 
I  have  seen  but  one  over  eighteen  months  of  age ;  this  was  in  a  child  four 
years  old.  Occasionally  scurvy  occurs  in  infants  under  six  months  of 
age,  but  this  is  unusual.  My  youngest  case  was  in  a  nursing  baby 
three  weeks  old.  In  this  infant  there  was  a  separation  of  the  epiphyses 
at  both  wrists. 

Etiology. — The  immediate  toxic  agent  causing  the  hemorrhagic 
condition  has  not  been  discovered.  It  seems  proved  that  there  is  some 
constitutional  error,  usually  due  to  nutritional  defects,  which  prepares 
the  individual  for  whatever  form  of  toxemia  may  be  operative. 

In  most  instances  the  nutritional  defect  may  be  ascribed  to  the  use 
of  cooked  foods.  The  well-known  collective  investigation  of  the  Ameri- 
can Pediatric  Society  established  the  influence  of  foods  that  had  been 
subjected  to  the  influence  of  heat.  Thus,  10  patients  were  entirely 
breast-fed,  4  were  getting  raw  cow's  milk,  116  were  on  pasteurized, 


SCURVY  (scorbutus)  113 

sterilized,  or  condensed  milk  feeding,  214  were  on  proprietary  foods. 
So  pronounced  a  factor  is  cooked  food  in  the  production  of  scurvy  that 
in  all  cases  so  fed  I  invariably  give  orange-juice,  2  or  3  teaspoonfuls 
daily. 

The  heating  of  milk  invariably  removes  something  from  it  which  is 
necessary  for  the  prevention  of  scurvy;  nevertheless,  such  cooking  does 
not  interfere  with  its  nutritional  properties.  This  I  have  demonstrated 
in  hundreds  of  cases. 

Symptoms. — Malnutrition  is  not  necessary  for  the  development  of 
scurvy,  neither  is  previous  illness  a  factor  of  much  consequence. 

The  first  sign  noticed  is  that  of  evident  pain  upon  manipulation  of 
different  portions  of  the  body,  most  frequently  one  of  the  legs.  The 
complaint  is  that  the  child  cries  when  the  napkin  is  changed,  or  when 
he  is  being  bathed  or  dressed.  Further,  the  child,  instead  of  freely 
moving  his  arms  and  legs,  allows  one  or  more  of  his  limbs  to  rest,  while 
the  others  may  be  moved  freely. 

In  advanced  cases  all  the  limbs  may  be  involved,  and  the  child 
makes  no  attempt  at  even  changing  the  position  of  a  limb,  and  cries 
vigorously  when  such  a  change  is  made.  The  position  taken  by  the 
child  is  that  of  outward  rotation  of  the  limb  or  limbs  affected. 

In  advanced  cases  the  involved  joint  or  joints  will  be  swollen.  The 
swelling  may  involve  the  entire  limb.  In  a  case  occurring  in  my  service 
at  the  Babies'  Hospital  the  leg,  from  above  the  knee  downward,  was 
twice  the  size  of  the  unaffected  leg. 

Upon  manipulation  the  parts  are  excruciatingly  tender.  I  have  re- 
peatedly had  mothers  complain  that  the  child  who  previously  had  en- 
joyed attention  in  the  way  of  handling  and  holding,  preferred  to  lie 
quietly  in  his  crib  and  apparently  feared  to  be  touched. 

While  the  long  bones  are  usually  involved,  the  other  bony  parts  may 
be  affected.  In  two  children  the  ribs,  spine,  and  scapula  were  affected. 
The  extremities  were  normal.  Both  infants  were  about  nine  months  of 
age.  They  cried  vigorously  when  they  were  lifted  by  placing  the  hands 
around  the  body  under  the  arms.  The  diagnosis  of  scurvy  was  proved 
by  the  quick  and  complete  response  to  orange-juice  and  the  use  of  un- 
cooked food. 

A  few  ecchymotic  areas  may  be  found  on  the  skin,  but  this  is 
unusual. 

Too  much  emphasis  is  placed  upon  this  symptom,  which  is  not  an 
early  manifestation  and  may  not  appear  for  two  or  three  or  more 
weeks  after  the  first  manifestation  of  the  local  lesion  in  the  limbs.  If 
the  condition  is  not  recognized,  submucous  bleeding  almost  invariably 
appears,  and  is  characteristic,  providing  the  child  has  teeth  in  the  upper 
jaw;  the  gums  in  the  lower  jaw  are  rarely  involved.  The  gums  are 
swollen,  edematous,  and  bleed  readily.  Over  teeth  about  to  be  erupted, 
blood  blebs  of  a  dark-bluish  color  may  be  seen.  In  the  absence  of 
teeth  the  gums  are  usually  normal.  In  a  very  few  cases  I  have  seen  a 
slight  bluish  discoloration.  It  is  only  in  the  very  advanced  cases  that 
the  lower  gum  and  teeth  will  show  involvement. 
8 


114  THE    PRACTICE    OF    PEDIATRICS 

Hematuria  to  a  slight  degree  is  present  in  most  cases.  In  a  few 
instances  it  has  been  severe,  showing  macroscopic  blood.  Blood  in  the 
stools  is  of  very  rare  occurrence. 

Prognosis. — The  prognosis  is  very  favorable.  All  cases  recover  if 
a  reasonably  early  diagnosis  is  made  and  proper  treatment  instituted. 
If  there  is  simply  an  involvement  of  a  joint,  of  short  duration,  the  child 
may  be  well  in  two  to  five  days.  In  cases  in  which  extensive  lesions 
have  formed,  two  or  three  weeks  or  more  may  be  required  for  complete 
recovery.  The  longest  time  under  treatment  in  my  cases  was  three 
months.  The  patient  was  a  baby  eighteen  months  of  age.  He  was 
taken  to  Dr.  V.  P.  Gibney,  who  recognized  the  condition  at  once  and 
referred  the  child  to  me  for  treatment.  The  child  had  been  treated  for 
rheumatism  for  three  months.  All  four  extremities  were  swollen  to 
twice  or  three  times  their  natural  size,  and  were  swathed  in  bandages, 
each  saturated  with  a  different  lotion  or  liniment.  In  this  way  each 
liniment  was  to  be  tested  out  and  the  one  that  served  best  was  to  be 
selected  for  all  the  limbs.  The  odors  emanating  from  the  child  were 
those  of  a  chemical  establishment  in  active  operation. 

All  previous  local  applications  employed  and  those  in  use  having 
failed,  the  case,  with  complete  paralysis  of  all  the  extremities,  was  con- 
sidered a  suitable  one  for  the  orthopedist.  In  addition  to  the  symp- 
toms described,  the  gums  were  bleeding  freely.  In  this  child,  the  most 
severe  case  I  have  seen,  the  progress  toward  improvement  was  very 
slow.  There  was  much  extravasated  blood  to  be  absorbed,  and  in- 
fractions— how  many  I  was  not  able  to  determine — to  be  healed. 
Resolution  was,  however,  eventually  complete. 

Differential  Diagnosis. — Scurvy  in  infants  was  formerly  most  fre- 
quently confused  with  rheumatism.  The  age  for  scurvy — under 
eighteen  months — is  not  the  age  for  rheumatism.  Scurvy  is  a  disease 
of  early  infancy,  and  rheumatism,  a  disease  of  childhood.  In  rheuma- 
tism fever  is  a  usual  symptom.  In  scurvy  there  is  no  fever.  From 
poliomyelitis  scurvy  may  be  differentiated  by  the  acute  pain  upon 
manipulation  and  the  presence  of  the  knee-jerk.  Specific  epiphysitis 
may  be  mistaken  for  scurvy  if  the  upper  extremity  is  involved.  The 
absence  of  other  signs  of  syphilis,  and  a  negative  Wassermann  test,  will 
render  a  differentiation  possible.  Further,  in  any  case  which  is  doubt- 
ful, the  use  of  orange-juice  will,  in  a  few  days,  through  relieving  the 
symptoms  of  scurvy,  determine  the  diagnosis.  This  is  a  perfectly 
innocent  procedure  upon  any  evidence  of  pain  in  any  of  the  limbs. 

Supposed  trauma,  such  as  a  sprain  or  a  fall,  is  the  interpretation 
often  applied  to  the  symptoms  of  scurvy.  Trauma  in  infants  is  most 
unusual,  but  possible,  and  the  treatment  test,  orange-juice,  may  be 
required  to  differentiate. 

Treatment. — Dietetic. — The  first  step  in  the  treatment  is  to  supply 
fresh  milk  for  the  child,  diluted,  if  necessary,  to  meet  the  digestive 
capacity.  I  have  seen  cases  in  which  the  diagnosis  was  made  early 
recover  without  the  aid  of  any  other  measure  upon  a  change  from 
sterilized  milk  or  infant  foods  to  raw  milk.     Inasmuch  as  the  disease 


RACHITIS    (rickets)  115 

is  a  most  painful  one,  every  means  possible  should  be  employed  toward 
furnishing  early  relief.  If  orange-juice  is  not  well  tolerated,  beef-juice 
may  be  given,  or  the  juice  of  any  ripe  fruit,  suitably  diluted.  The 
orange-juice  very  exceptionally  disagrees  with  the  digestion.  A 
scorbutic  child  who  has  never  tasted  orange-juice  will  take  it  greedily 
and  beg  for  more.  One  teaspoonful  may  be  given  at  two-hour  intervals, 
1  ounce  being  given  ordinarily  in  twenty-four  hours.  Unless  the  case 
is  an  advanced  one,  with  extensive  subperiosteal  hemorrhages  and  sepa- 
ration of  the  epiphyses,  relief  will  be  noticed  in  twenty-four  hours  and 
an  entire  cessation  of  symptoms  in  from  five  to  seven  days.  I  have 
seen  a  few  cases  entirely  relieved  at  the  end  of  seventy-two  hours  of 
treatment.  These  patients  were  infants  in  whom  the  diagnosis  was 
made  very  early,  the  only  symptom  being  the  evidence  of  pain  during 
manipulation  of  the  limbs  in  bathing  or  while  changing  the  napkin. 

The  management  of  more  severe  cases  is  the  same  as  of  those  of 
milder  type.  Fresh  food,  with  orange-juice  or  beef-juice,  must  be 
freely  given.  The  patients  should  be  handled  very  gently,  and  only 
when  necessary,  as  the  pain  on  manipulation  of  the  involved  parts  is 
most  excruciating.  In  cases  of  epiphyseal  separation  splints  should  be 
temporarily  applied. 

RACHITIS  (RICKETS) 

Rickets  was  described  by  Whistler  in  1645,  and  again  in  1650  by 
Glisson.  The  disease  has  been  more  wide-spread  in  countries  with  cool, 
temperate  climates  than  in  tropical  or  semitropical  regions,  where  the 
inhabitants  live  for  the  most  part  out-of-doors.  Similarly,  this  disease 
shows  a  slightly  greater  tendency  to  develop  during  the  winter  than  in 
the  summer.  Attempts  to  define  the  exact  etiology  of  the  condition  have 
uniformly  failed.  Most  of  the  prevailing  theories  have  been  reviewed 
by  Dr.  R.  G.  Freeman,*  who  found  the  disease  most  frequent  in  insti- 
tution babies  who  were  fed  on  breast-milk  supplemented  by  artificial 
feedings  of  condensed  milk.  In  his  opinion,  both  unsuitable  food  and 
infection  or  toxemia  from  the  alimentary  tract  may  be  influential 
causes. 

Siegert  in  1903  expressed  the  view  that  rickets  was  often  hereditary, 
supporting  his  belief  by  observations  of  severe  cases  in  the  breast-fed 
children  of  rachitic  parents.  By  other  authorities,  however,  rickets  of 
congenital  origin  is  held  to  be  improbable  or  in  any  event  exceedingly 
rare. 

Rickets  is  a  chronic  disease  of  nutrition.  Its  chief  manifestations 
are  in  the  bones  during  the  growing  period.  It  is  peculiar,  however, 
in  that  a  greater  part  of  the  structure  which  goes  to  make  up  the  infant 
organism  may  be  involved  in  the  rachitic  process,  which  is  in  effect  a 
metabolic  derangement  of  wide  possibilities. 

Age. — Rickets  may  occur  at  any  age  after  the  first  month.  It 
usually  makes  its  appearance  between  the  third  and  the  twelfth 
months.     Few  cases  develop  before  the  first  month, 

*  "The  Etiology  of  Rachitis,"  R.  G.  Freeman,  Archives  of  Pediatrics,  April, 
1904. 


116  THE    PRACTICE    OF    PEDIATRICS 

Etiology. — Italian  and  negro  infants  show  a  decided  predisposition 
to  rachitis.  A  negro  or  Itahan  baby  between  six  and  twelve  months 
of  age  in  New  York  City  without  some  evidence  of  rachitis  is  a  curiosity. 

Much  has  been  written  regarding  the  etiology  of  the  disease  in 
its  relation  to  climatic  and  unhygienic  surroundings.  While  such  sur- 
roundings may  contribute  to  the  result,  I  have  yet  to  be  convinced 
that  as  etiologic  factors  they  are  very  important.  It  is  true  that  we 
often  find  rachitic  children  in  unhygienic  surroundings,  but  thousands 
of  others  who  live  under  the  same  conditions  do  not  have  rachitis. 
A  child  fed  on  normal  breast-milk  will  endure  and  thrive  in  an  environ- 
ment that  typifies  "unhygienic  conditions"  (a  popular  term  with 
writers). 

In  the  treatment  of  several  thousand  rachitic  children  one  fact 
has  impressed  me  most  strongly:  A  child  suffering  from  rachitis  is 
suffering  from  nutritional  errors  as  a  result  of  improper  feeding  or 
inability  to  assimilate  a  suitable  food;  and  I  have  yet  to  see  a  case  which 
will  not  improve  when  suitable  nourishment  can  be  given  and  assimi- 
lated, regardless  of  the  age  of  the  patient,  provided,  of  course,  there 
is  no  other  disease.  In  children  under  one  year  of  age  prolonged 
feeding  of  the  proprietary  foods  or  sweetened  condensed  milk  is  the 
most  frequent  cause  of  the  disease.  The  next  most  frequent  cause 
is  the  feeding  of  a  too  strong  cow's-milk  mixture,  which  produces 
indigestion  and  faulty  assimilation. 

Rachitis  in  the  Breast-fed. — Breast-fed  babies  among  the  Italians 
and  negroes  often  have  mild  rachitis,  and  an  examination  of  the 
breast-milk  will  invariably  show  a  diminution  of  one  or  more  of  the 
nutritional  elements — usually  the  proteid. 

A  nursing  woman  in  the  New  York  Infant  Asylum  had  such  a 
free  flow  of  milk  that  a  foster-child  was  given  her  to  nurse.  The 
children  failed  to  thrive;  each  made  a  gain  of  but  two  or  three  ounces 
weekly;  both  developed  rachitis,  one  in  a  marked  degree.  Repeated 
examinations  of  the  breast-milk  showed  it  never  to  contain  more  than 
1.5  per  cent,  fat,  4  per  cent,  sugar,  and  0.5  per  cent,  proteid. 

I  have  time  and  again  seen  rachitis  in  breast-fed  infants  in  whom 
the  milk  was  adequate  in  amount,  but  deficient  in  nutritional  elements. 
These  cases  will  most  often  be  seen  from  the  seventh  to  the  tenth 
month. 

After  the  First  Year. — After  the  first  year  fewer  cases  develop,  but 
a  late  rachitis  is  by  no  means  uncommon.  In  my  own  cases  the  de- 
velopment of  the  disease  at  one  year  and  after,  as  in  the  very  young, 
has  been  distinctly  traceable  to  faulty  feeding  and  faulty  digestion. 

Prolonged  Nursing. — Not  a  few  cases  during  the  second  and  third 
years  are  due  to  prolonged  nursing.  I  have  known  just  two  mothers 
who  could  nurse  their  children,  and  substantially  nourish  them,  by  the 
breast,  later  than  the  twelfth  month.  Usually  when  the  breast  fur- 
nishes the  only  means  of  nourishment  after  the  ninth  month,  a  be- 
ginning rachitis  will  soon  be  noticed.  The  feeding  after  the  first  year 
of  an  exclusive  diet  of  milk  or  of  digestible  starches  is  not  infrequently 


RACHITIS    (rickets)  117 

a  cause  of  rachitis.  Among  the  poorer  classes  children  during  the 
second  and  third  years  are  almost  always  badly  fed.  The  diet  often 
consists  of  poor  milk  and  poorly  cooked  starches.  Children  thus  fed 
furnish  no  small  proportion  of  our  rachitic  patients. 

Association  with  Other  Diseases. — The  development  of  rachitis 
bears  no  relation  to  other  disorders,  excepting  in  its  influence  upon 
the  nutrition  of  the  patient. 

Theories  of  Pathogenesis. — Deficiency  of  lime  salts  in  the  system, 
either  as  the  result  of  poor  food  or  faulty  assimilation,  has  been  long 
regarded  as  the  cause  of  the  disease,  but  investigation  has  proved  that 
rachitic  subjects  do  not  present  the  supposed  variations  from  the 
normal,  either  in  alkalinity  of  the  blood  or  in  lime  elimination. 

Experiments  in  depriving  young  animals  of  fat  have  failed  to 
render  them  rachitic.  Attempts  at  bacterial  inoculation  have  like- 
wise afforded  no  convincing  results. 

Monti,  of  Vienna,  was  able  to  demonstrate  a  diminution  in 
hydrochloric  acid  associated  with  an  excess  of  lactic  acid  in  the 
stomachs  of  affected  infants,  and  he  coupled  with  this  discovery  the 
observation  that  the  disease  was  more  prevalent  among  the  breast- 
fed infants  of  Saxony,  whose  mothers  received  little  salt  in  their  food, 
than  in  communities  where  the  individual  intake  of  sodium  chlorid 
was  normal. 

Recently,  Hirschfeld  has  demonstrated  the  existence  of  a  vaso- 
constrictor substance  in  the  serum  of  rachitic  infants.  To  the  presence 
of  this  substance  he  ascribes  the  frequent  coexistence  of  simple  rickets 
with  tetany,  eczema,  and  such  catarrhal  conditions  of  the  mucous 
membranes  as  are  indicative  of  a  so-called  exudative  diathesis. 

In  the  state  of  confusion  arising  from  so  many  diverse  theories  we 
may  summarize  the  results  of  clinical  evidence  in  only  a  few  facts: 
Rickets  is  infrequent  in  the  breast-fed,  unless  colored  or  Italian;  rela- 
tively infrequent  amid  good  hygienic  surroundings;  rare  before  the 
age  of  three  or  four  months,  and  uniformly  absent  from  infants  who 
have  been  taking  and  assimilating  a  substantial,  well-proportioned  food. 

Pathology. — The  most  obvious  changes  are  in  the  bones.  Here 
there  is  indeed  a  marked  deficiency  of  lime  salts.  The  formation  of 
bone  is  interfered  with  not  only  at  the  epiphyses,  but  also  in  the  region 
subjacent  to  the  enveloping  periosteum. 

In  the  epiphyseal  ends  of  the  long  bones  there  is  an  excessive  pro- 
liferation of  the  cartilage  cells,  and  an  abnormal  vascularization  of 
the  zones  of  proliferation  and  calcification,  which  intervene  between 
epiphysis  and  diaphysis.  The  deposit  of  lime  salts  in  the  cartilaginous 
matrix  is  imperfect,  and  the  solid  cartilage  undergoes  a  variable 
amount  of  absorption.  As  a  result  of  these  changes  the  epiphyses 
are  softened  and  enlarged  and  the  bones  are  subjected  to  varjnng 
deformities. 

Associated  with  the  defective  development  at  the  epiphysis  there 
is  likewise  incomplete  formation  of  bone  beneath  the  periosteum. 
This  membrane  is  thickened,  and  the  subperiosteal  layer  of  bone, 


118  THE    PRACTICE    OF    PEDIATRICS 

which    normally  undergoes    calcification,   is   vascularized,   soft,   and 
deficient  in  calcium  salts. 

"  The  pathologic  changes  may  be  summed  up  in  the  statement  that 
there  is  excessive  absorption  of  the  bone  with  impairment  of  the 
process  of  calcification."*  When  the  disease  subsides,  the  imperfect 
bone  undergoes  calcification  and  hardening,  but  retains  the  deformities 
previously  acquired.  The  enlargement  of  the  epiphysis  characteristic 
of  rickets  is  usually  first  apparent  at  the  costochondral  joints,  which 
acquire  the  well-known  beaded  appearance  suggestive  of  the  title, 
"rachitic  rosary."  In  the  more  advanced  cases  the  thorax  under- 
goes actual  distortions,  defined  by  the  terms,  "Harrison's  grooves" 
and  "pigeon-breast."  Curvatures  of  the  spine  and  pelvic  deformities 
which  may  be  combined  with  lordosis  are  common.  In  severe  cases 
the  legs  become  curved,  owing  to  the  inability  of  the  bones  to  sus- 
tain the  weight  of  the  body,  and  portions  of  the  cranial  vault  may 
undergo  a  variable  amount  of  absorption.  Localized  areas  of  thin- 
ness in  the  occipital  and  parietal  bones  are  characteristic  of  the 
craniotahes  of  rickets.  The  affected  skull  is  large  and  the  centers  of 
ossification  of  the  frontal  and  parietal  bones  are  marked  by  hyper- 
ostoses or  bosses.  In  many  instances  the  anterior  fontanel,  instead 
of  becoming  closed  at  the  twentieth  month,  remains  patent  until  the 
third  or  fourth  year.  The  eruption  of  the  teeth  is  uniformly  delayed 
and  irregular. 

Although  rickets  is  fundamentally  a  disease  of  general  nutrition, 
the  lesions,  apart  from  those  occurring  in  the  osseous  system,  are  of 
relatively  slight  significance.  The  spleen  is  frequently  enlarged;  less 
often,  the  liver.  The  stomach  and  colon  maybe  dilated.  The  muscles 
undergo  wasting,  slight  degenerative  changes,  and  a  variable  amount 
of  fatty  infiltration.  The  ligaments  are  relaxed.  The  blood  shows 
the  existence  of  a  secondary  anemia  and  a  mononuclear  leukocytosis. 
Most  of  these  conditions  may,  however,  be  considered  secondary  to, 
rather  than  characteristic  of,  the  disease. 

Symptoms. — In  a  vast  majority  of  the  cases  there  are  no  symp- 
toms depending  upon  the  presence  of  the  disease.  There  may  be 
sweating  of  the  head,  restlessness,  constipation;  but  these  symptoms 
are  also  present  in  cases  which  show  no  rachitic  change.  There  is 
usually  malnutrition,  and  yet  malnutrition  may  be  present  without 
rachitis.  Rachitic  children  are  unusually  susceptible  to  catarrhal 
conditions  of  the  respiratory  tract  and  they  have  a  weak  resistance 
to  infection  of  the  intestines;  yet,  again,  we  find  these  conditions  in 
children  who  do  not  have  rachitis.  In  rachitic  children  there  is  pro- 
nounced lack  of  nerve  balance,  and  this  occurs  in  children  who  do  not 
have  rachitis.  All  these  conditions  are  present  in  rickets,  and  as  a 
symptom-complex  they  point  to  rachitis.  Such  symptoms,  therefore, 
are  not  diagnostic  without  further  corroboration. 

So  far  as  the  pathognomonic   symptoms   are  concerned,   which 
means  the  conclusive  manifestations  of  a  disease,  there  are  none. 
*Adami  and  Nicholls:  Principles  of  Pathology,  vol.  ii,  p.  1009. 


RACHITIS    (rickets)  119 

The  signs  proving  rachitis  comprise  the  physical  appearance  of 
the  child,  the  findings  upon  physical  examination,  and  the  evidence 
demonstrated  by  postmortem  examinations. 

Diagnosis. — In  a  well-marked  case  inspection  shows  a  condition 
that  is  seen  in  no  other  disease.  There  is  the  large  head,  cuboid  in 
shape,  flat  on  the  top,  due  somewhat  to  the  exaggeration  of  the  frontal 
and  parietal  eminences.  The  beading  of  the  ribs  stands  out  plainly. 
The  chest  is  narrow,  retracted  at  the  sides,  and  increased  in  the  antero- 
posterior diameter,  producing  the  so-called  pigeon-breast.  In  pro- 
nounced cases  there  often  is  an  axillary  groove  extending  the  length 
of  the  chest.  A  rare  deformity  is  the  funnel-chest,  in  which  there  is  a 
marked  retraction  of  the  lower  portion  of  the  sternum,  greatly  decreas- 
ing the  anteroposterior  diameter  at  this  point,  with  a  corresponding 
increase  in  the  lateral  diameter. 

The  epiphyses  of  both  the  upper  and  lower  extremities  are  enlarged, 
and  there  is  a  decided  outward  curvature  of  the  tibia.  There  may  also 
be  anterior  bowing  of  the  femur.  The  radius  and  ulna  may  also  show 
curvature,  but  this  is  less  usual.  Knock-knee  is  present  in  a  com- 
paratively small  number  of  cases. 

The  child  has  a  pot-belly,  often  with  umbilical  hernia. 

Physical  examination  reveals  a  large  fontanel,  two  or  three  times 
the  size  normal  for  the  age.  Dentition  is  delayed;  repeatedly  infants 
of  a  year  and  over  will  not  have  erupted  a  tooth.  Craniotabes,  which 
consists  of  soft,  compressible  areas  in  the  skull  showing  deficient 
deposit  of  bone-cells,  is  present  in  many  young  rachitic  infants. 

A  non-angular  posterior  spinal  curvature  involving  several  vertebrae 
will  be  found  in  a  majority  of  the  patients  under  fifteen  months  of 
age.  This  is  due  to  muscle  and  ligament  weakness,  and  will  be  proved 
by  suspending  the  child  by  the  arms,  when  the  curvature  will  usually 
disappear.  This  straightening  may  not  completely  take  place  in  older 
children,  in  whom  the  deformity  has  existed  for  several  months.  Fur- 
ther, in  older  cases  there  may  be  associated  lateral  and  rotatory 
curvatures. 

The  clavicle  may  show  thickening  at  the  ends,  and  in  severe  cases 
I  have  repeatedly  seen  an  increase  in  the  anterior  curve. 

In  a  large  out-patient  and  hospital  service  extending  over  many 
years  in  different  institutions  all  types  of  deformities  have  been 
presented,  an  enumeration  or  description  of  which  would  add  nothing. 

Rachitic  children  will  be  found  abnormal  in  other  respects.  There 
is  usually  a  secondary  anemia.  They  possess  poor  resistance  to 
bacterial  infection,  and  when  such  infection,  or  in  fact  any  disease, 
occurs  the  chances  of  recovery  are  less  than  in  a  normal  individual. 
The  nerve  resources  are  of  a  low  order.  Convulsions  may  occur  upon 
slight  irritation.  The  digestion  is  rarely  up  to  the  normal  for  the 
child's  age. 

It  is  to  be  understood  that  in  this  description  I  have  been  con- 
sidering a  well-marked  case.  Hundreds  of  children  show  varying 
degrees  of  mild  rachitis  in  which  the  conditions  may  in  no  way  com- 


120  THE    PRACTICE    OF    PEDIATRICS 

promise  the  individual.  Further,  it  must  be  appreciated  that  not 
every  case  shows  the  even  distribution  of  the  lesions  enumerated. 
There  may  be  cases  with  bowed  legs  or  knock-knees,  spinal  deformity, 
or  enlarged  cranium,  in  which  one  of  the  conditions  mentioned  may  be 
the  only  sign  of  consequence. 

Differential  Diagnosis. — That  confusion  arises  in  differentiating 
rachitis  from  cretinism,  mongolianism,  and  hydrocephalus  is  demon- 
strated in  consultation  practice.  A  clear  mental  picture  as  to  what 
constitutes  mongolianism,  cretinism,  and  rachitis  would  eliminate 
confusion  without  the  assistance  of  a  consultant.  A  differentiation, 
however,  between  the  large,  rachitic  head  and  one  due  to  an  acquired 
hydrocephalus  or  to  a  mild  degree  of  congenital  hydrocephalus  is  not 
a  simple  matter,  for  the  reason  that  when  there  is  hydrocephalus  there 
is  usually  rachitis.  An  immediate  diagnosis  is  impossible.  I  have 
known  most  competent  neurologists  to  ask  for  time  for  further  ob- 
servation before  making  a  diagnosis.  The  further  observation  has 
usually  included  repeated  measurement  of  the  circumference  of  the 
child's  head.  A  child's  head  increases  in  circumference  from  birth 
onward  about  as  follows:  During  the  first  year,  4  inches,  3  inches  of 
which  is  increase  during  the  first  six  months ;  during  the  first  and  second 
year,  1  inch;  during  the  second  to  the  third  year,  3^  to  ^^  inch;  during 
the  third  to  the  fifth  year,  l^i  inches.  When  the  rate  of  growth 
considerably  exceeds  these  figures,  it  is  an  indication  of  a  hydro- 
cephalus. A  prominent  fontanel  and  ununited  sutures  indicate 
hydrocephalus.     (See  p.  510.) 

Prognosis. — The  prognosis  is  favorable  in  so  far  as  the  immediate 
disease  is  concerned.  Uncomplicated  with  intercurrent  disease,  all 
cases  recover  if  properly  treated.  Indirectly,  because  of  the  sus- 
ceptibility to  infection  and  the  lack  of  resistance,  rachitis  is  a  large 
factor  in  the  mortality  of  the  young.  Cured  patients  suffer  no  in- 
convenierice  in  later  life.  There  is  doubtless  some  shortening  in 
stature;  it  is  difficult  to  determine  the  effects  in  this  respect,  as  there 
are  no  means  of  knowing  what  height  the  individual  might  have 
attained  had  he  not  had  rachitis.  In  women  at  childbirth  its  baneful 
possibilities  are  made  prominent  in  narrow  and  contracted  pelves. 

Treatment. — It  will  readily  be  seen,  from  the  foregoing,  that  the 
treatment  of  rachitis  resolves  itself  into  the  adjustment  of  the  diet  to 
the  needs  of  the  patient.  As  growth  and  normal  development  cannot 
take  place  without  proteid  and  salts,  and  as  the  history  of  our  cases 
has  shown  that  these  are  the  elements  which  are  most  frequently 
lacking  in  the  diet  of  rachitic  children,  suitable  feeding  should  be  our 
first  consideration. 

Diet  of  Infants. — Artificial  foods  usually  are  deficient  in  both  the 
fat  and  proteid;  therefore  these  foods  should  be  discontinued.  I 
have  seen  a  vast  number  of  cases  that  were  on  cow's-milk  feeding  of 
such  strength  that  it  could  not  be  assimilated.  In  practically  all 
cases  a  properly  adapted  cow's-milk  formula  is  the  only  treatment 
required. 


RACHITIS    (rickets)  121 

Diet  After  the  First  Year. — For  those  over  one  year  of  age  not  only 
should  artificial  food  be  discontinued  and  cow's  milk  given,  but  the 
cow's  milk  should  be  supplemented  by  a  diet  rich  in  nitrogen.  I 
order  a  diet  composed  largely  of  milk,  scraped  beef,  soft-boiled  egg, 
oatmeal,  and  wheat  gruel.  After  the  second  year  purees  of  beans 
and  peas  are  added  to  the  dietary  because  of  the  large  percentage  of 
proteid  which  they  contain.  It  is  impossible  to  prescribe  a  more 
definite  dietary.  The  physician  must  remember  that  a  diet  as  highly 
nitrogenous  as  the  child  can  assimilate  is  to  be  given.  Unfortunately, 
many  rachitic  children  cannot  take  cow's  milk  in  quantities  sufficient 
to  make  it  of  real  nutritive  value.  This  is  often  the  result  of  an  in- 
ability to  digest  the  fat,  the  milk  being  taken  without  inconvenience 
when  a  large  proportion  of  the  fat  is  removed.  Skimmed  milk  con- 
tains at  least  3  per  cent,  of  the  nutritional  element  most  desired,  the 
proteid,  and  makes  a  valuable  addition  to  the  diet.  If  a  dilution  of 
the  milk  is  necessary,  oatmeal  gruel  should  be  used. 

Many  children  who  cannot  take  a  full  milk  diet  will  take  an  ounce 
or  two  of  butter  daily  without  inconvenience.  For  older  children  I 
advise  the  free  use  of  butter,  one  or  two  ounces  daily.  It  is  advisable 
to  give  rachitic  children  a  moderate  amount  of  fat,  as  it  aids  in  the 
production  of  heat  and  thus  saves  the  tissues.  Before  the  second 
year  of  age  cod-liver  oil  is  often  a  valuable  addition  to  the  dietary. 
In  prescribing  cod-liver  oil  I  prefer  to  use  the  plain  oil.  In  spite  of 
the  disgust  adults  have  for  cod-liver  oil,  children  usually  take  it 
readily.  The  younger  the  child,  the  better  the  oil  will  be  taken. 
To  delicate  children  six  months  of  age  from  10  to  30  drops  may  be 
given  three  times  daily  after  meals.  From  the  sixth  to  the  eighteenth 
month,  from  20  drops  to  1  dram  may  be  given  three  times  daily  after 
feedings.  After  the  eighteenth  month,  from  1  to  3  drams  may  be 
given  three  times  daily  after  meals. 

Hygiene. — Brine  baths  and  oil  inunctions  aid  materially  and  are  of 
great  value  in  improving  the  child's  condition  as  a  whole.  The  brine 
bath  (p.  780),  which  is  given  at  bedtime,  is  followed  by  an  inunction  of 
goose-grease,  unsalted  lard,  or  cacao-butter.  The  goose-oil  or  lard  is 
preferred.  At  least  two  teaspoonfuls  should  be  rubbed  into  the  skin. 
The  benefit  derived  from  the  inunctions  is  largely  due  to  the  massage. 
The  rubbing  should  be  continued  for  at  least  ten  minutes.  The 
muscles  of  the  back  and  legs  should  receive  special  attention.  In  a 
few  instances  the  animal  fats  act  as  irritants  to  the  skin  and  produce 
a  fine,  papular  eruption. 

The  rachitic  child  should  have  plenty  of  fresh  air,  by  means  either 
of  a  fireplace  or  an  open  window.  On  stormy  and  very  cold  days  he 
should  be  given  an  indoor  airing  (p.  762),  being  placed  in  his  carriage 
or  cart  and  wheeled  about  the  room.  To  avoid  drafts,  the  window 
or  windows  on  only  one  side  of  the  room  should  be  opened. 

Rachitic  children  are  very  susceptible  to  head  colds  and  bronchitis ; 
therefore,  every  means  must  be  employed  to  prevent  exposure.  As 
creeping  and  playing  on  the  floor  are  the  most  frequent  methods  of 


122  THE    PRACTICE    OF    PEDIATRICS 

taking  cold,  the  exercise  pen  (p.  767)  is  particularly  useful  in  these 
cases. 

Drugs. — Drugs,  in  my  experience,  are  of  value  only  as  they  increase 
the  appetite  and  the  capacity  for  properly  selected  foods.  The  ad- 
ministration of  phosphorus  is  without  avail  if  the  deficient  diet  is  con- 
tinued. Specific  medication  without  proper  food  and  a  fair  digestive 
capacity  is  valueless.  With  proper  food  and  a  fair  digestive  capacity, 
medication  is  siiperfluous,  and  a  child  rapidly  recovers  without  it. 

I  have  used  phosphorus  extensively,  and  have  yet  to  see  a  single 
case  in  which  the  beneficial  action  of  the  drug  could  be  proved.  In 
giving  phosphorus,  the  oleum  phosphoratum  is  the  easiest  and  most 
convenient  form  for  administration.  One  drop  of  the  preparation 
represents  3^1^00  grain  of  phosphorus.  To  children  under  one  year  of 
age  1  drop  may  be  given  three  times  daily.  To  those  between  the 
first  and  second  year,  13^^  to  2  drops  may  be  given  three  times  daily 
after  meals. 

Deformities. — The  deformities  of  the  osseous  system,  particularly 
of  the  spine  and  long  bones,  may  be  prevented — the  first,  by  keeping 
the  child  on  his  back  a  greater  part  of  the  time,  and,  if  the  deformity  is 
well  marked,  by  teaching  him  to  sleep  resting  on  his  stomach.  When 
a  kyphosis  is  present,  the  child  should  be  allowed  to  remain  in  the 
upright  position  but  a  few  moments  at  a  time. 

Deformities  of  the  femur,  tibia,  and  fibula  occur  long  before  the 
child  attempts  to  stand,  but  too  early  use  of  the  legs,  while  not  neces- 
sarily a  cause  of  deformity,  may  greatly  aggravate  the  existing  condi- 
tions. For  this  reason  rachitic  children  should  not  be  encouraged  to 
walk  or  stand  until  they  have  been  under  treatment  for  three  or  four 
months. 

Operative  measures  for  the  correction  of  bow-legs  are  better  post- 
poned until  after  the  third  year.  If  corrected  at  an  earlier  period, 
the  deformity  is  apt  to  return,  and  the  late  deformity  may  be  greater 
than  the  original  one. 

In  my  experience  the  use  of  the  braces  to  correct  the  deformity  of 
the  legs  has  been  of  but  little  assistance,  nor  has  any  patient  of  mine 
been  benefited  particularly  when  so  treated  by  the  orthopedic  surgeon. 
The  use  of  braces  and  jackets  of  plaster-of-Paris  in  kyphosis  is  usually 
unnecessary.  Rest,  massage,  and  exercises  directed  to  restoring  power 
to  the  weakened  muscles  have  answered  well, 

THE  DELICATE  CHILD 

In  pediatric  practice  one  frequently  meets  with  children  who, 
while  they  cannot  be  said  to  be  suffering  from  any  disease  or  patho- 
logic condition,  yet  are  inferior  in  physical  development.  They  lack 
endurance,  and  possess  poor  resisting  powers.  They  are  usually  under 
height,  always  under  weight,  and,  in  short,  have  so  many  character- 
istics in  common  that  they  constitute  a  class  by  themselves,  and  as 
such  warrant  our  attention. 


THE    DELICATE    CHILD  123 

Normal  Development. — The  average  child,  at  the  various  periods 
of  early  life,  conforms  with  a  certain  degree  of  regularity  to  the  mental 
and  physical  development  which  by  long  association  we  have  come  to 
regard  as  normal.  Thus  a  standard  may  be  said  to  have  been  estab- 
lished, and  it  is  up  to  this  standard  that  we  expect  the  growing  child 
to  measure.  This  is  what  we  look  upon  as  the  average  of  physical 
and  mental  development.  A  few  children  exceed  these  requirements 
and  are  stronger  and  larger  at  the  sixth  month  than  the  average 
child  at  the  ninth  month.  Again,  older  children  at  the  fourth  or 
fifth  year  may  be  in  every  way  equal  to  their  normal  playmates  a 
year  or  two  older. 

Abnormal  Development. — On  the  other  hand,  there  are  children 
who  are  born  with  reduced  vitality,  or  who,  through  faulty  manage- 
ment, usually  in  relation  to  feeding,  acquire  a  reduced  vitality.  Semi- 
invalid  adults  almost  invariably  beget  semi-invalid  children.  If  the 
parents  are  of  average  health  and  of  good  habits  and  the  debilitated 
condition  of  the  child  is  due  to  faulty  management  and  nutritional 
errors,  the  result  of  proper  dietetic  and  hygienic  management  is  usually 
prompt  and  satisfactory.  With  the  persistently  delicate,  the  offspring 
of  physically  enfeebled  parents,  the  results  are  less  satisfactory. 

Treatment. — By  proper  regulation  of  the  habits  of  a  delicate  child, 
as  regards  all  the  details  of  his  daily  life,  a  far  better  adult  is  produced 
than  if  no  such  effort  has  been  made.  In  other  words,  a  diet  and  gen- 
eral regime  of  life  best  adapted  to  the  individual  in  question  will  in- 
variably improve  the  physical  condition  of  that  individual.  This 
applies  to  the  strong  as  well  as  to  the  delicate,  to  the  growing  young  of 
the  lower  animals  as  well  as  to  the  offspring  of  man.  It  is  the  poorly 
developed,  delicate  child  that  we  are  particularly  to  consider — the 
undersized,  frail,  small-boned  child,  whose  appetite  is  persistently  poor 
or  capricious,  who  sleeps  poorly,  tires  easily,  is  usually  constipated, 
who  is  subject  to  catarrhal  conditions  of  the  respiratory  tract,  and 
whose  powers  of  resistance  generally  are  diminished. 

On  assuming  the  management  of  one  of  these  children  it  is  abso- 
lutely necessary  to  make  a  thorough  examination,  followed  in  some  in- 
stances by  a  few  weeks'  observation,  in  order  to  become  acquainted 
with  the  case  in  its  individual  aspects,  to  learn  idiosyncrasies,  and  to 
eliminate  the  factor  of  actual  disease  as  a  causative  agent.  When  we 
demonstrate  to  our  satisfaction  that  the  child  is  free  from  such  diseases 
as  tuberculosis,  syphilis,  and  malaria;  when  we  have  eliminated  by 
properly  directed  treatment  all  causes,  such  as  adenoids,  otitis,  phimo- 
sis, adherent  clitoris,  vaginitis,  or  parasitic  and  irritant  skin  lesions, 
which  may  have  had  a  deterrent  influence  upon  gro^\i;h;  and  when  we 
have  satisfied  ourselves  as  to  the  actual  condition  of  our  patient,  we  are 
in  a  position  to  lay  down  definite  rules  of  management. 

Every  child  has  a  distinct  function  to  perform.  As  soon  as  he  is 
born  he  is  confronted  with  a  serious  problem — the  problem  of  physical 
and  mental  growth.  Inasmuch  as  this  growth  and  development  de- 
pend, above  all  things,  upon  a  properly  adapted  food-supply,  it  must 


124  THE    PRACTICE    OF    PEDIATRICS 

be  our  first  step  to  provide  such  nutriment  as  will  be  most  conducive 
to  growth.  As  growth  takes  place  in  all  parts  of  the  body  through 
cellular  activity,  the  nutritive  elements  which  support  cell  prolifera- 
tion must  be  important  constituents  of  the  diet,  and  among  these  the 
proteids  are  of  prime  importance;  hence  in  the  management  of  these 
children  a  point  to  be  remembered  in  the  adaptation  of  the  food  is  the 
necessity  of  feeding  as  rich  a  proteid  as  the  child  can  assimilate.  The 
younger  the  child,  the  greater  the  necessity  for  growth. 

Regular  Weighings  Necessary. — An  infant  should  be  weighed  at 
regular  intervals,  and  if  under  one  year  of  age,  should  not  be  considered 
as  doing  even  passably  well  if  not  gaining  at  least  four  ounces  weekly. 
When  a  baby  remains  stationary  in  weight,  the  development  is  in- 
variably abnormal.  When  the  weight  is  stationary  or  when  only  a 
slight  gain  of  one  or  two  ounces  weekly  is  made,  we  always  find  after 
a  few  weeks  that  there  is  malnutrition,  in  spite  of  the  apparent  gain,  as 
will  be  evidenced  by  the  symptoms  of  beginning  rickets — anemia,  the 
characteristic  bone  changes,  flabby  muscles,  and  a  tendency  to  disease 
of  the  mucous  membranes.  Delicate  infants  should  be  weighed  daily 
at  first;  then,  as  improvement  takes  place,  at  intervals  of  two  or  more 
days,  but  never  less  frequently  than  once  a  week,  during  the  first  year, 
no  matter  how  vigorous  they  may  become.  The  weighing  keeps  us 
directlj^  in  touch  with  the  child's  condition,  but  since  the  increase  may 
be  in  fat  alone,  an  occasional  examination  of  the  child  stripped  is 
necessary  to  tell  us  whether  there  is  substantial  growth  in  bone  and 
muscle. 

Feeding  Infants. — When  it  is  demonstrated  that  a  child  will  not 
thrive  on  the  breast  of  the  mother,  another  breast  should  be  sub- 
stituted, or  an  adapted  high-proteid  cow's  milk  should  supplement  or 
replace  the  breast  milk.  If  the  child  is  bottle-fed  and  it  is  demon- 
strated that  proper  growth  and  development  are  impossible  on  cow's 
milk,  on  account  of  proteid  incapacity,  then  a  wet-nurse  should  be 
secured. 

When,  after  the  first  year,  more  liberal  feeding  is  allowed,  the  neces- 
sity for  a  high  proteid  in  the  food  selected  is  as  urgent  as  before.  This 
applies  to  those  children  who  are  brought  to  us  showing  evidences  of 
late  malnutrition,  as  well  as  to  those  whom  we  have  had  under  our  care 
from  early  infancy. 

An  important  element  in  the  diet  up  to  the  third  year  is  milk.  A 
child  from  the  first  to  the  third  year  ought  to  receive  one  pint  of  milk 
daily.  Unfortunately,  many  debilitated  children  have  a  very  poor 
capacity  for  fat  assimilation.  When  given  full  milk  in  as  small  an 
amount  as  one  pint  daily,  they  often  develop  foul  breath,  coated 
tongue,  and  loss  of  appetite,  or  they  suffer  from  frequent  attacks  of 
acute  indigestion.  The  milk  is  necessary,  not  because  of  the  fat, 
which  can  easily  be  dispensed  with,  but  because  of  the  high  percentage 
of  proteid  which  it  contains — from  3  to  4  per  cent.  When  this  fat 
incapacity  exists,  the  milk  is  said  to  "disagree,"  although  skimmed 
milk  will  be  taken  without  inconvenience.     Enough  sugar  may  be 


THE    DELICATE    CHILD  125 

added  to  bring  the  percentage  up  to  seven,  in  order  that  the  extra 
sugar  may  replace  the  fat  for  fuel.  Skimmed  milk  with  sugar  added 
furnishes  a  food  of  no  mean  order.  Too  much  milk,  however,  must 
not  be  given.  When  more  than  one  quart  daily  is  taken,  the  desire  for 
more  substantial  nourishment,  such  as  eggs,  meat,  and  cereals,  is 
removed. 

Diet  After  the  First  Year. — At  the  completion  of  the  first  year,  keep- 
ing in  mind  a  high  proteid  we  may  give  scraped  beef,  at  first  one  tea- 
spoonful  once  a  day,  in  addition  to  the  cereal  and  milk.  If  the  beef  is 
well  borne,  and  it  usually  is,  a  teaspoonful  may  be  given  twice  a  day, 
and  later  three  times  a  day,  immediately  before  the  bottle-feeding. 
Eggs  should  be  brought  into  use  from  the  twelfth  to  the  fifteenth 
month.  At  first  one-half  an  egg,  boiled  two  minutes,  is  given  mixed 
with  bread-crumbs.  If  well  borne,  a  whole  egg  may  be  allowed.  The 
cereals  used  should  be  those  richest  in  vegetable  proteid,  such  as  oat- 
meal, containing  16  per  cent,  of  proteid,  dried  peas,  with  20  per  cent, 
of  proteid,  and  dried  beans,  containing  24  per  cent,  of  proteid.  The 
peas,  beans,  and  lentils  should  be  given  in  the  form  of  a  puree. 

If  the  child  during  the  second  year  has  an  indifferent  appetite,  the 
quantity  of  milk  should  be  reduced,  never  more  than  one  pint  of 
skimmed  milk  being  permitted  daily  for  the  first  week  or  two.  Many 
delicate  children  who  apply  for  treatment  after  the  first  year  of  age 
have  been  subjected  to  as  grave  errors  in  diet  as  are  seen  among  the 
bottle-fed.  Starch  and  milk  frequently  furnish  the  only  nutrition 
up  to  the  fourth  or  fifth  year,  the  starch  used  being  generallj^  in  the 
form  of  bread,  crackers,  and  ill-cooked  cereals.  In  one  case  four 
quarts  of  milk  were  taken  daily  by  a  boy  of  seven  years. 

In  dealing  with  this  class  of  children — the  delicate,  undersized, 
slow-growing  class — it  is  our  aim  to  give  as  liberal  nitrogenous  nourish- 
ment as  is  compatible  with  the  digestive  capacity  of  the  patient.  If, 
however,  the  child  has  had  rheumatism,  or  if  there  is  a  tendency  to 
lithiasis,  the  use  of  a  large  amount  of  meat  is  contraindicated.  For 
such  children  the  high-proteid  cereals  are  particularly  valuable.  In 
general,  from  early  life  the  diet  of  the  delicate  child  should  consist  of 
milk,  suitably  adapted,  with  highly  nitrogenous  cereals  added  when 
permissible.  Many  delicate  children  of  the  "runabout"  age  who  can- 
not digest  milk  containing  4  per  cent,  of  fat  will  easily  digest  butter- 
fat  spread  on  bread  or  potatoes.  In  this  way  I  often  use  butter  to 
supply  fuel  to  act  as  a  proteid-sparer.  Oatmeal-water,  or  oatmeal 
jelly,  mixed  with  the  milk  should  be  ordered  at  the  seventh  month. 
When  age  allows,  the  addition  of  rare  meat,  poultry,  eggs,  and  purees 
of  dried  peas,  beans,  and  lentils  should  be  made.  Boxed,  "ready  to 
serve"  cereals  are  never  given;  raw  cereals  are  provided  which  are 
cooked  three  hours.  While  a  high-proteid  diet  is  desirable,  other  foods 
are  necessary.  Green  vegetables,  animal  fats,  the  ordinary  cereals, 
cooked  and  raw  fi-uits,  are  required  to  furnish  the  necessary  acids  and 
salts,  as  well  as  the  necessary  variety.  In  short,  the  ideal  diet  for  a 
delicate   child  is  that  combination  of   foods  which,  while  imposing 


126  THE    PRACTICE    OF   PEDIATRICS 

the  least  burden  upon  the  digestive  organs,  supplies  the  body  with 
material  sufficient  for  its  needs.     (See  dietary,  p.  105.) 

Baths. — On  account  of  the  fear  that  a  delicate  child  may  take  cold, 
the  bath  is  often  omitted.  All  children,  both  the  well  and  the  delicate, 
after  the  second  week  should  be  tubbed  daily;  the  delicate  particularly 
require  bathing.  The  salt  bath  (p.  780)  is  usually  advised.  The  best 
time  for  giving  the  bath  is  at  bedtime,  and  in  order  to  avoid  all  chance 
of  exposure  the  temperature  of  the  room  should  be  elevated  to  80°F. 
The  temperature  of  the  water  may  vary.  It  should  never  be  above 
95°F.  except  for  very  delicate  young  children  in  whom  there  is  a 
tendency  to  a  subnormal  temperature.  Even  in  these  cases  the  tem- 
perature of  the  bath  should  never  be  higher  than  the  temperature  of 
the  body.  For  the  frail  and  the  very  young,  the  bath  should  not  be 
continued  over  five  minutes.  In  bathing  children  of  eighteen  months 
or  over,  if  the  physical  conditions  allow,  a  distinct  advantage  will  be 
gained  by  a  reduction  of  the  temperature  of  the  bath  while  the  child  is 
in  the  water.  An  immersion  in  water  at  90°F.,  followed  by  a  gradual 
reduction  during  the  space  of  five  or  six  minutes  to  70°F.,  should,  upon, 
brisk  rubbing,  be  followed  by  quick  reaction.  For  children  after  the 
third  year,  a  graduated  cold  spinal  douche  has  served  me  well,  (See 
Spinal  Douche,  p.  779.)  If  the  reaction  is  not  good,  if  the  extremities 
are  cold  and  are  slow  in  becoming  warm,  the  reduction  in  the  tempera- 
ture should  be  less  or  none  at  all.  With  the  very  poorly  nourished,  a 
reduction  below  80°F.  should  not  be  attempted.  Following  the  drying 
process,  primarily  for  the  benefit  of  the  massage,  goose  oil,  unsalted 
lard  or  olive  oil  should  be  rubbed  into  the  skin  over  the  entire  body  for 
five  to  ten  minutes.  The  bath  and  massage  inunction,  besides  favor- 
ably influencing  nutrition,  are  very  effective  in  inducing  sleep. 

Fresh  Air. — Delicate  children  are  usually  deprived  of  a  proper 
amount  of  fresh  air,  for  the  same  reason  that  they  are  insufficiently 
bathed — the  fear  of  making  them  ill.  All  children  need  an  abundance 
of  fresh  air  both  in  illness  and  in  health.  To  the  delicate  fresh  air  is 
even  more  essential  than  to  the  robust.  As  many  hours  daily  as 
practicable  should  be  spent  out-of-doors.  The  time  thus  spent  de- 
pends upon  the  season  of  the  year  and  the  residence  of  the  child, 
whether  in  the  city  or  the  country.  In  the  city,  during  the  colder 
months  with  pleasant  weather,  the  child  should  spend  at  least  five 
hours  daily  in  the  open  air,  dividing  the  day  into  two  outing  peiods — 
from  9  to  11.30  in  the  morning  and  from  2  to  4.30  in  the  afternoon. 
On  very  cold  days  (20°F.  or  below),  on  stormy  days,  and  on  days  with 
very  high  winds,  the  child  should  be  given  his  airing  indoors.  He  is 
dressed  as  for  out-of-doors,  placed  in  his  carriage,  and  left  in  a  room, 
the  windows  on  one  side  of  which  are  open.  Not  infrequently  during 
February  and  March  delicate  children  will  be  prevented  from  going 
out-of-doors  for  several  consecutive  days.  If  some  means  for  a  daily 
systematic  indoor  airing  is  not  provided,  these  children  will  often  go 
backward,  no  matter  how  excellent  the  other  management.  The 
first  symptoms  are  loss  of  appetite  and  the  ability  to  assimilate  food. 


THE    DELICATE    CHILD  127 

In  my  private  work  among  athreptics,  the  child  is  placed  in  the  baby- 
carriage  or  in  a  basket  and  allowed  to  rest  before  an  open  window  for 
ten  or  twelve  hours  of  every  twenty-four,  with  a  hot-water  bottle  at 
his  feet.  Here  he  is  fed,  being  removed  only  temporarily  to  warmer 
quarters  for  a  change  of  napkins,  I  have  three  roof-gardens  in  opera- 
tion. A  boy  patient,  nine  months  of  age,  was  taken  to  the  street 
only  once  in  four  months,  then  only  going  to  church  to  be  baptized. 

Sleep. — The  delicate  child  requires  no  more  sleep  than  does  the 
strong,  and  the  rules  governing  this  function  at  the  various  periods  of 
life  are  the  same  both  for  the  strong  and  for  the  weak.  (See  Sleep,  p. 
45.)  The  sleeping-room  of  the  delicate  child  should  always  communi- 
cate with  the  open  air  by  a  window,  either  directly  or  through  an 
adjoining  room.  A  satisfactory  means  of  ventilation  is  the  window- 
board  (p.  138).  The  child  should  occupy  the  room  alone,  if  possible, 
sharing  it  neither  with  an  adult  nor  another  child.  This  ruling  applies 
to  all  ages,  but  is  particularly  necessary  after  the  second  year. 

The  Nursery. — The  temperature  of  the  nursery,  day  or  night,  should 
never  be  above  70°F.  during  the  colder  months.  Very  young  infants, 
and  those  who  are  with  difficulty  kept  covered,  should  not  sleep  in  air 
below  65°F. 

Delicate  children  of  the  ''runabout"  age  are  very  susceptible  to 
colds.  In  the  management  of  such  children  it  is  necessary  to  use  every 
precaution  against  exposure.  The  most  frequent  way  of  exposing  a 
child  to  cold  is  by  allowing  him  to  sit  on  the  floor.  To  keep  the 
child  of  ten  months  to  three  years  of  age  off  the  floor  during  the  winter 
months,  and  thereby  to  eliminate  this  means  of  exposure,  is  very  diffi- 
cult. In  fact,  with  active  children  learning  to  walk,  or  who  have  just 
learned  to  walk,  it  is  practically  impossible  under  the  usual  conditions. 
During  the  colder  months  there  is  always  a  current  of  cold  air  near  the 
floor,  and  allowing  the  child  to  creep  in  winter,  even  if  the  floor  is  pro- 
tected by  rugs  and  carpets,  is  one  of  the  surest  ways  of  permitting  him 
to  take  cold.  If  he  is  not  allowed  to  walk  on  the  floor,  he  is  very  sure 
soon  to  sit  down.  If  he  is  not  allowed  to  creep  and  walk  about  at  will, 
he  will  not  get  the  proper  exercise  and  will  show  faulty  development. 
For  such  cases,  I  have  found  the  exercise  pen  of  immense  service. 
(See  p.  767.)  After  being  dressed,  washed,  and  fed,  the  child  is  placed 
in  the  pen,  on  a  rug  if  desired.  Toys  are  given  him  and  the  door  is 
closed.  He  can  now  roam  about  at  will,  stand  up,  sit  down,  creep  or 
walk  without  the  slightest  danger  from  drafts. 

Influence  of  Climate. — Much  has  been  written  regarding  the  influ- 
ence of  climate  in  the  type  of  case  we  are  considering.  According  to 
my  observation,  this  matter  does  not  deserve  the  attention  it  has  re- 
ceived. The  city  child  in  a  well-to-do  family  is,  as  a  rule,  better  off  for 
eight  months  of  the  year  in  his  own  home  with  its  usual  conveniences. 
The  benefits  attributed  to  change  in  climate  are  usually  the  result  of  a 
change  not  of  climate,  but  to  more  fresh  air,  which  is  afforded  by  the 
larger  rooms  of  the  hotel,  with  its  loosely  constructed  doors  and  win- 
dows ;  and  the  fact  that,  since  the  parent  is  desirous  that  the  child  shall 


128  THE    PRACTICE    OF    PEDIATRICS 

receive  the  full  benefit  of  the  change,  he  is  kept  in  the  open  air  for  a 
much  longer  time  than  when  at  home.  The  air  at  such  a  place  is  more 
expensive,  and  consequently  more  appreciated  than  the  air  at  home. 
With  sufficient  heat  and  proper  ventilation,  we  may  make  our  own 
cHmate.  It  is  not  to  be  denied,  however,  that  a  change  of  residence 
for  a  few  weeks,  during  March  and  April,  from  New  York  to  Lakewood 
or  Atlantic  City,  is  sometimes  of  advantage. 

From  the  first  of  June  to  the  first  of  October  the  delicate  child  should 
not  remain  in  any  large  city  if  removal  is  possible.  The  humidity  and 
the  heat  which  may  prevail  for  protracted  periods  during  this  time 
render  the  city  unsafe,  particularly  during  July  and  August.  The 
seashore  for  the  entire  summer  is  not  to  be  advised.  The  children 
whom  I  have  sent  inland  to  the  country  and  to  the  mountains  have,  as 
a  rule,  returned  in  the  autumn  in  much  better  physical  condition  than 
those  who  spend  the  summer  by  the  sea. 

Clothing. — Thin,  poorly  nourished  children  require  more  clothing 
than  do  those  physically  normal.  A  fairly  good  index  as  to  whether 
a  child  is  sufficiently  clad  is  the  condition  of  his  lower  extremities.  The 
forearm  and  hand  cannot  be  relied  upon.  The  legs  and  feet  of  every 
child  should  always  be  warm  to  the  touch. 

As  clothing,  a  mixture  of  silk  and  wool  next  to  the  skin  is  most 
desirable.  Although  less  desirable,  a  mixture  of  wool  and  cotton  may 
be  used.  The  linen  mesh,  often  useful  for  the  vigorous  "runabout," 
is  not  to  be  advised  for  the  delicate. 

Exercise. — Exercise  is  to  be  encouraged,  but  should  never  be  allowed 
to  the  point  of  fatigue.  In  large  cities  all  delicate  "runabouts"  from 
three  to  five  years  of  age  should  be  allowed  to  walk  not  more  than  six 
blocks  in  going  to  the  playgrounds.  If  the  distance  is  greater,  the 
child  should  ride  part  of  the  way,  play  or  walk  for  a  time,  and  then  be 
placed  in  the  carriage  or  cart  and  ride  home.  Younger  children,  two 
to  three  years  of  age,  should  be  wheeled  both  ways  and  taken  out  at 
the  park  for  a  run  when  the  weather  conditions  permit. 

Midday  Nap. — Every  day  after  the  midday  meal  the  child,  regard- 
less of  age,  whether  two  years  or  six,  should  be  undressed  and  put  to 
bed  for  two  hours.  He  should  be  left  alone  in  the  room,  and  whether 
he  sleeps  or  not  he  should  remain  in  bed  for  the  two  hours. 

Entertainment. — Entertaining  play  is  necessary,  but  every  kind  of 
excitement,  such  as  children's  parties,  emotional  plays  at  the  theater, 
and  rough  play  with  older  children,  should  be  avoided. 

Now  and  then  I  meet  with  a  case  among  the  well-to-do  in  which, 
because  of  prolonged  faulty  feeding  or  vicious  heredity,  the  vital  spark 
is  so  low  that,  fan  it  as  we  may,  no  impression  upon  it  is  made.  As  a 
rule,  these  stubborn  cases  are  the  offspring  of  alcoholism  and  de- 
bauchery. The  patients  are  thin,  anemic  infants;  they  develop  into 
thin,  anemic  children,  and  into  thin,  anemic  adults.  The  delicate 
and  degenerate  are  found  in  all  the  walks  of  life,  but  they  are  especially 
numerous  in  dispensaries  and  in  children's  institutions. 

Much  of  the  work  of  the  pediatrist  is  with  the  weakly  of  the  so- 


THE    DELICATE    CHILD  129 

called  ''better  class."  His  success  in  the  management  of  these  delicate 
children  depends  largely  upon  the  home  cooperation,  and  a  promise 
of  this  should  be  obtained  before  taking  the  case.  The  parents  must 
be  taught  that  the  development  of  the  intellect,  the  character,  and 
the  body  go  hand  in  hand  and  that  a  vigorous  intellect  is  rarely  found 
without  a  vigorous  body.  They  must  be  convinced  that  the  body 
is  more  than  a  machine.  It  has  delicate  organs  to  keep  in  repair  and 
supply  with  energy.  It  has  a  nervous  organization;  it  has  sensibilities. 
The  normal  exercise  of  all  these  functions  demands  the  normal  nourish- 
ment of  the  body.  In  my  experience,  family  cooperation  in  a  few 
instances  has  been  difficult  to  obtain.  The  parents  began  well,  but 
soon  tired  of  the  extra  work  required.  The  care  of  the  young  has 
always  been  undertaken  in  such  a  wretched,  unscientific  manner  that 
it  is  difficult  to  make  the  untrained  mind  appreciate  the  necessity  of 
careful  attention  to  details  in  management. 
9 


II.  EXAMINATION  AND  DIAGNOSIS— CARE  OF  ACUTE 

ILLNESS 

DIAGNOSIS 

Before  a  student  in  diseases  of  children  is  shown  a  sick  child,  he 
should  be  made  thoroughly  familiar  with  the  normal  child  of  approxi- 
mately the  following  ages :  under  three  months,  one  year,  three  years, 
five  years,  and  ten  years. 

He  should  learn  the  normal  appearance  of  the  eyes,  ears,  throat, 
skin,  genitals,  and  the  character  of  the  stools  of  the  various  ages.  He 
should  be  instructed  in  the  examination  of  the  liver,  spleen,  abdomen, 
heart,  and  lungs 

In  teaching  diagnosis  in  children  in  postgraduate  work,  covering 
a  period  of  twenty- six  years,  I  have  repeatedly  been  impressed  with 
the  handicap  under  which  many  physicians  work  because  of  a  very 
indifferent  conception  of  the  normal. 

Without  sufficient  ability  to  examine  the  canal  and  drum  of  the 
ear,  and  to  know  the  possibilities  for  variations  within  the  normal,  it 
it  futile  to  attempt  the  recognition  of  diseased  processes. 

Many  physicians  expert  in  pulmonary  diagnosis  in  adults  are 
wholly  unable  to  make  out  even  approximately  diseased  conditions 
in  the  lungs  of  infants  and  young  children.  These  are  all  conditions 
that  cannot  be  taught  in  a  didactic  way.  Neither  can  one  learn  much 
of  the  subject  through  reading.  What  is  required  is  the  examination 
of  the  normal  infant  or  young  child — not  a  few  examinations,  but  a 
very  careful  routine  examination  of  many  infants  and  young  children. 
A  point  most  difficult  to  determine  is  the  borderland  between  normal 
and  diseased  processes,  as  evidenced  by  physical  signs. 

Diagnosis  in  children  requires  ability  to  estimate  the  condition 
as  a  whole.  The  fact  that  the  patient  cannot  describe  his  symptoms 
is  of  more  advantage  than  detriment.  The  child  appears  in  the 
perfectly  natural  condition,  without  attempt  to  mislead,  with  no 
preconceived  ideas  or  theories.  In  other  words,  the  child,  unless 
alarmed,  is  always  natural,  always  himself;  this  is  a  very  definite  aid. 
Further,  the  young  child  has  no  imagination.  He  is  never  hypo- 
chondriac. Instead  of  giving  the  impression  that  he  is  more  ill,  he 
is  liable  to  be  judged  less  ill  than  he  really  is,  because  of  his  activities 
and  disinclination  to  give  up.  This  tendency  to  remain  active  may 
be  misleading.  When,  therefore,  a  child  appears  very  ill,  while  the 
condition  may  not  be  dangerous,  we  may  always  know  that  he  feels 
very  badly. 

Physicians  who  wish  to  become  expert  in  diagnosis  must,  first 
learn  the  normal  child  from  birth  until  he  passes  into  the  adult. 

130 


diagnosis  131 

Diagnosis  by  Inspection 

We  must  learn  the  appearance  and  bodily  habit  of  the  child  under 
normal  conditions.  Thus  the  baby  of  a  few  weeks  cries  when  hungry, 
and  with  incoordinate  movements  of  the  arms  and  legs  expresses  his 
discomfort.  With  colic  or  pain  of  any  nature  he  also  cries,  and  with 
incoordinate  movements  of  hand  and  legs  makes  known  his  discom- 
fort. But  the  child's  manner  of  crying  and  the  movements  of  the 
body  are  in  no  way  alike.  A  baby  spoiled  and  who  wants  to  be  taken 
up  also  makes  a  great  ado,  and  yet  he  acts  vastly  different  than  when 
he  is  in  hunger  or  pain. 

All  the  above  manifestations  are  vastly  different  from  the  cry  and 
the  arhythmic  movements  of  early  meningitis. 

The  position  in  which  the  child  rests  in  bed  often  supplies  us  with 
very  good  evidence  as  to  the  nature  of  the  trouble.  Thus  one  posi- 
tion is  assumed  in  meningitis;  another  in  paraplegia;  and  another  in 
scurvy  or  poliomyelitis.  The  countenance  or  the  facial  expression 
may  be  indicative  of  the  disorder.  The  anxious,  flushed  countenance 
of  acute  pneumonia,  with  the  dilatation  of  the  alse  nasi  and  the  rapid 
breathing  and  grunt,  are  all  strongly  suggestive.  The  sunken  eyes, 
the  expressionless  countenance,  the  ashy  pallor,  the  superficial  breath- 
ing, all  characterize  the  appearance  of  the  patient  with  intestinal 
toxemia. 

The  diagnosis  of  malnutrition  and  marasmus  is  always  stamped  on 
the  countenance.  In  cretinism,  in  Mongolian  idiocy,  in  micro- 
cephaly and  other  forms  of  mental  deficiency,  the  name  of  the  dis- 
order is  written  on  each  countenance,  and  for  diagnosis  we  need  go 
little  further. 

The  blue-white  skin  of  anemia,  the  pallor  of  nephritis,  with  the 
fulness  about  the  eyes,  are  often  diagnostic  in  themselves.  Among 
the  transmissible  diseases,  measles,  mumps,  and  chicken-pox,  are 
readily  diagnosed  by  inspection.  In  scarlet  fever,  also,  inspection 
is  our  greatest  aid. 

In  hemiplegia  the  quiet  arm  and  leg,  with  the  other  arm  and  leg 
in  motion,  are  strongly  suggestive  as  to  the  nature  of  the  trouble. 

The  only  way  in  which  whooping-cough  may  be  positively  diag- 
nosed is  to  watch  the  child  during  a  paroxysm. 

By  inspection  we  can  fairly  accurately  determine  the  existence  of 
acute  laryngitis  or  membranous  laryngitis.  As  mentioned  elsewhere, 
the  obstruction  in  acute  laryngitis  is  inspiratory,  while  in  membranous 
laryngitis  it  is  both  expiratory  and  inspiratory. 

The  position  of  the  head,  the  dysphagia,  and  the  peculiar  cracked 
voice  mark  retropharyngeal  abscess.  The  method  or  peculiarities  of 
locomotion  supply  most  valuable  evidences  of  Pott's,  hip  or  other 
bone  and  joint  diseases.  In  tetany,  the  "accoucheur's"  hand,  and 
the  feet  in  extreme  extension,  are  all  that  are  necessary  for  diagnosis. 

The  yellow  conjunctivae  and  the  tinted  skin  indicate  jaundice. 
In  the  skin  diseases  or  skin  manifestations  of  any  nature  inspection 
again  is  an  important  means  of  diagnosis. 


132 


THE    PEACTICE    OF    PEDIATRICS 


The  facial  expression  due  to  adenoids  is  so  characteristic  that  every 
text-book  contains  a  photograph  demonstrating  the  "adenoid  face." 

Laryngismus  stridulus,  convulsions,  tonsillitis,  rachitis,  scurvy,  and 
stomatitis  are  all  diagnosed  by  inspection. 

It  will  readily  be  seen  what  a  great  aid  in  diagnosis  is  possessed  by 
the  physician  who  possesses  trained  powers  of  observation. 

Inspection  During  Sleep. — It  is  of  advantage  to  observe  many 
children  when  they  are  asleep,  and  beyond  all  the  influences  of  their 
surroundings.  In  not  a  few  cases  correct  respiratory  observations  are 
possible  only  when  the  child  is  asleep. 

FIRST  EXAMINATION 

Upon  being  called  upon  for  the  first  time  to  see  a  patient,  it  is  my 
custom  in  every  case  to  take  a  history.  Below  is  a  copy  of  the  history 
record  which  I  use.  Form  A  represents  the  front  of  the  slip.  Form 
B  represents  the  back  of  the  same  slip.  Further  records  are  kept  on 
plain  ruled  sheets  of  the  same  size — 5  by  8  inches. 

HISTORY  RECORD 


FORM  A 

Date                 Address                                      Name 

Mr.                                                Age 

Family  History       Children  living         Ch.  dead          Cause 

Rheumatism                          Tuberculosis 

Syphilis 

Nervous  Dis.                         Alcohol,  tea,  etc. 

Miscarriages 

Personal  History                  child,  born  at                 Labor                 Wt.  at  B.         lb. 

Sat  up  at           mo.       Talked  at     mo.     Teeth  at 

mo.          Walked  at     mo. 

General  Health  and  Habits 

Appetite                                 Eats  between  meals  ^ 

Tea,  beer,  etc.? 

Bowels                                                Bath 

Fresh  air 

Sleeps             from         to             ;  and  from         to 

.     Snores?     Mouth  Br.? 

Previous  Diseases    Meas.         Wh.  Cg,         C-Pox 

Scarlet.         Diphth. 

Mumps.             Sm-Pox. 

Gastro-enteric 

Respiratory 

Ear                                          Throat 

Colds 

Diet  from  Birth     Nursed 

Present  History 

FORM  B 

Weight  lb.     Height 

General  Condition 

Mentality 
Head     Fontanel 
Eyes 

Mouth  Tongue 
Throat 

Lymph  Nodes 
Thorax  Shape 
Heart 
Lungs 

Abdomen  Umbilicus 

Genitals  Skin 

Extremities    Epiphyses  Contour 

°.P.     .R     .  Blood    R.B.C. 
Urine     React.     S.  G.     Alb.         S. 


EXAMINATION 

in.     Circ.  Head 
Color 
Sits?  Walks? 

Sutures 
Nose  Disch. 
Muc.  Memb. 
Tonsil 
Ears 
Rosary 


in.  Circ.  Chest  in. 

Muscles  Reflexes 

Talks? 
Cranio-tabes 
Breathing 
Teeth 
Adenoids 
Epitrochlears 
Groove 


Liver 

Feet 
Hb. 


Spleen 


Ind. 


Ace. 


Mic.  Exam. 


%.  W.B.C. 


ESSENTIALS    IN    THE    CARE    OF    ACUTE    ILLNESS  133 

When  the  history  is  completed,  the  leaves  are  placed  in  a  Moore's 
loose-leaf  binder. 

The  patient's  family  history  is  carefully  taken.  The  habit  of  ob- 
taining a  complete  and  accurate  record  of  family  peculiarities  in  rela- 
tion to  disease  is  often  of  much  service,  subsequently,  if  not  at  the 
time.  Only  upon  systematic  questioning  will  necessary  facts  be 
brought  out  relating  to  tuberculosis,  rheumatism,  syphilis,  etc.  The 
child's  personal  history  includes  the  birth- weight,  the  rate  of  growth, 
the  nature  of  previous  illnesses,  present  weight,  the  condition  of  the 
skin,  eyes,  nose,  heart,  lungs,  tongue,  bowels,  bones,  and  the  tem- 
perature. All  these  points  are  noted  and  recorded.  It  is  only  by 
such  an  examination,  requiring  much  time  and  patience,  that  we 
are  able  to  become  thoroughly  acquainted  with  the  case  in  hand. 

The  child  must  be  stripped  for  the  examination,  when  the  condi- 
tions found  are  entered  in  the  proper  spaces  in  the  history  chart. 
After  the  family  history  has  been  taken  and  the  general  phj^sical 
examination  is  completed,  we  are  in  a  position  to  devote  ourselves 
to  the  present  condition  of  the  patient.  After  one  has  practised  for 
a  time,  thoroughly  examining  every  new  case,  he  is  impressed  not 
only  wdth  the  value  of  the  method  as  bearing  upon  the  management 
of  the  condition  in  question,  but  also  with  the  unexpected  pathologic 
findings  in  other  organs,  particularly  the  heart,  throat,  and  lungs. 

ESSENTIALS  IN  THE  CARE  OF  ACUTE  ILLNESS 

Our  first  intention,  in  our  relation  with  a  sick  child,  regardless  of 
the  nature  of  the  illness,  is  to  appreciate  the  changed  conditions  which 
exist.  A  well  child,  regardless  of  the  position  he  may  occupy  in  the 
social  scale,  subscribes  to  a  certain  living  regime,  which  should  be  so 
fashioned  as  to  supply  the  requirements  of  nutrition  and  healthy 
growth,  which  means  normal  development.  Thus,  he  is  fed,  clothed, 
and  has  the  benefit  of  fresh  air,  exercise,  and  bathing.  When  the 
child  becomes  ill,  his  position  temporarily  is  changed,  and  in  order 
for  us  to  act  to  his  best  interest,  radical  changes  must  be  instituted 
in  order  to  meet  this  changed  condition  as  regards  appetite,  sleep, 
the  digestive  capacity,  and  quiet.  The  great  majority  of  the  serious 
illnesses  in  children  are  acute  in  character.  Every  child  begins  the 
illness  with  a  definite  number  of  strength  units.  Vitality  and  re- 
sistance determine  in  no  small  degree  the  issue  of  the  disease.  We 
must  so  act  as  to  conserve  every  strength  unit. 

Our  first  duty,  then,  toward  the  sick  child  is  to  place  him  in  the 
most  favorable  position,  in  order  that  he  may  be  able  to  withstand 
the  ordeal  through  which  he  must  pass.  Regardless  of  the  nature 
of  the  disease,  certain  requirements  must  be  fulfilled  that  apply  to 
all  severe  illnesses,  the  general  management  of  which  in  children  is 
very  similar. 

Patient  to  be  Kept  in  Bed. — The  patient  is  to  be  kept  in  bed,  not 
held  on  the  lap.     The  handling  of  the  patient,  the  passing  from  one 


134  THE    PRACTICE    OF    PEDIATRICS 

person  to  another,  the  attempt  at  entertaining,  cause  active  excitement 
and  waste  energy,  when  quiet  is  necessary. 

Quiet  Attendants. — Attendants  who  are  quiet  and  agreeable  to 
the  child  should  care  for  him.  In  my  seriously  sick  cases — pneu- 
monia, endocarditis,  and  the  like — I  allow  but  one  person,  and  that 
the  attendant,  in  the  room  at  one  time. 

Clothing. — The  clothing  should  be  the  usual  night-clothing,  to 
which  the  patient  has  been  accustomed  in  health.  There  is  no  illness 
that  requires  extra  clothing  for  the  body  when  the  customary  room 
temperature  (66°  to  68°F.)  is  allowed.  Heavy  shirts  and  oiled  silk 
or  cotton- wool  jackets  are  never  to  be  employed,  regardless  of  the 
nature  of  the  illness. 

In  summer  the  lightest  clothing  should  be  used;  for  younger 
children  a  thin  linen  slip  with  the  addition  of  a  napkin  is  all  that  is 
required. 

Sponging. — The  patient  is  sponged  over  once  or  twice  a  day  for 
cleansing  purposes,  regardless  of  the  nature  of  the  illness.  During 
the  hot  days  of  summer  the  sponging  may  be  repeated  several  times 
with  advantage.  There  is  no  disease  of  childhood  in  which  the  appli- 
cation of  water  to  the  skin  is  a  dangerous  procedure.  On  the  con- 
trary, it  is  quite  necessary  that  the  skin  be  so  treated  that  it  functionate 
actively. 

The  Sick-room. — In  summer,  a  cool,  quiet  room,  large  if  possible, 
with  wide-open  windows,  or  its  equivalent  out-of-doors,  should  be 
selected  for  the  patient.  During  the  colder  months  a  generous  air 
space  is  most  desirable. 

Room  Temperature. — In  winter  the  thermometer  should  never 
go  above  70°F.  Hot,  ill-ventilated  rooms  depress  the  vital  powers. 
The  child  is  poisoned  by  carbonic  dioxid;  he  is  made  restless  and 
irritable.  He  uses  up  nerve  force  and  energy  is  wasted.  A  room 
temperature  of  66°  to  68°F.  is  best  under  most)  conditions.  There 
are  few  households  which  cannot  have  a  thermometer. 

Ventilation. — There  must  always  be  a  communication  between 
the  sick-room  and  out-of-doors.  A  convenient  means  of  ventilation 
is  the  window  board  (p.  138). 

Cold  Air. — I  am  not  inclined  to  advocate  cold  air  to  the  extreme 
degree  advised  by  some.  A  wide-open  window  during  illness,  such  as 
convalescence  from  acute  pulmonary  disease,  I  consider  an  excellent 
measure  if  the  child  is  suitably  protected  by  a  hood  and  an  extra 
outer  garment.  When  possible,  I  give  the  patient  the  advantage  of 
two  rooms,  one  for  use  during  the  day  and  one  for  the  night.  This 
is  of  particular  advantage  in  grip  and  in  the  respiratory  diseases  in 
which  there  is  a  possibility  of  reinfection.  The  room  which  is  not 
occupied  should  be  aired  continually. 

Drinking  of  Water.- — There  is  no  illness  of  childhood  in  which 
water  to  drink  should  not  be  given  freely.  If  there  is  any  question 
as  to  its  purity,  it  should  be  boiled. 


ESSENTIALS    IN    THE    CARE    OF    ACUTE    ILLNESS  135 

Diet. — The  digestive  capacity  of  every  sick  child  is  lessened;  this 
we  all  appreciate,  the  degree  of  incapacity  depending  largely  upon  the 
severity  and  nature  of  the  illness.  In  every  illness  the  food  strength 
should  be  lessened.  This  we  do  not  all  appreciate.  For  breast-fed 
babies  this  is  done  by  giving  water,  sugar-water,  or  some  cereal 
decoction,  as  barley-water,  before  each  nursing,  usually  from  two  to 
three  ounces.  This  dilutes  the  mother's  milk.  The  nursing  baby  is 
satisfied  when  his  stomach  is  full.  He  needs  as  much  fluid  as  usual, 
but  is  unable  to  digest  the  usual  amount  of  breast  milk.  For  the 
bottle  fed,  the  food  strength  is  reduced  by  substituting  water  for  a 
given  quantity  of  the  milk  mixture.  A  safe  rule  to  follow  is  to  reduce 
the  food  strength  one-half  by  the  addition  of  water.  If  the  illness  is 
a  very  severe  one  of  intestinal  disorder,  whether  typhoid  fever  or 
summer  diarrhea,  milk  is  discontinued  absolutely,  and  usually  cereal 
decoctions  are  substituted.  During  a  very  severe  attack  of  pneumonia 
or  scarlet  fever  the  milk  given  is  diluted  with  cereal  gruels.  When 
the  usual  feeding  is  continued,  gastro-intestinal  infection  is  sure  to 
add  to  the  burden  of  the  patient  through  toxins  absorbed  from  the 
putrefaction  of  undigested  milk  in  the  gut.  The  resulting  tympanites 
is  a  very  serious  feature  in  respiratory  and  cardiac  diseases.  Tym- 
panites embarrasses  the  action  of  the  overworked  or  diseased  heart 
and  interferes  with  respiration  already  sufficiently  obstructed  by  the 
processes  in  the  lungs  or  in  the  pleural  cavity.  The  carbohydrates 
leave  no  by-products  to  be  eliminated  by  the  kidneys,  thus  lessen- 
ing the  work  of  these  diseased  organs,  and  perhaps  preventing  their 
involvement  in  such  diseases  as  scarlet  fever  and  diphtheria,  by  dimin- 
ishing the  amount  of  irritation  to  which  they  may  be  subjected.  In 
short,  we  must  allow  just  as  much  food  as  the  patient  can  care  for. 
When  we  give  more,  we  diminish  the  chances  of  recovery  through 
added  toxemia  or  by  interfering  with  the  vital  processes. 

Needless  Interference. — Regardless  of  the  nature  of  the  severe 
illness,  we  must  conserve  vitality  by  disturbing  the  patient  as  little 
as  possible.  The  various  attentions  to  the  child  should  be  given  at 
distinct,  but  reasonably  long,  intervals.  It  is  rare  that  a  child  will 
need  food  or  medication  oftener  than  once  in  two  hours  during  the 
night — three  hours  answer  in  most  cases.  Food  and  medicine  may 
be  given  at  the  same  time.  Not  infrequently  I  see  cases  in  consulta- 
tion where  something  is  being  done  to  the  child  every  hour  in  the 
twenty-four.  This  would  exhaust  any  well  child.  What  can  the 
effect  be  upon  the  very  ill,  but  to  diminish  chances  of  recovery? 

Urine  Examination. — Nephritis  is  a  complication,  and  a  serious 
one,  that  may  be  looked  for  in  all  acute  diseases  of  children.  An  early 
recognition  of  this  complication  is  most  important.  Albumin  in  the 
urine  is  one  of  the  earliest  signs  of  nephritis,  and  involvement  of  the  kid- 
neys may  be  discovered  by  urine  examinations  before  any  of  the  other 
signs  of  nephritis  appear.  It  is  my  custom,  in  scarlet  fever  and  diph- 
theria, diseases  peculiarly  liable  to  nephritic  involvement,  to  examine 
the  urine  daily- — in  other  acute  diseases  with  fever,  at  two-  or  three-day 


136  THE    PRACTICE    OF    PEDIATRICS 

intervals.  This  examination  is  simplified  by  writing  a  prescription 
for  an  ounce  of  nitric  acid  (c.  p.)  and  a  few  test-tubes,  which  are  kept 
in  the  sick-room.  The  cold  test  is  sufficient  to  detect  the  smallest 
trace  of  albumin.  When  the  physician  must  carry  the  urine  with  him 
or  have  it  sent  to  his  home,  the  examination  is  sometimes  postponed 
or  otherwise  neglected. 

Bowel  Function. — Every  nurse  or  mother  is  given  a  standing  order 
that  there  is  to  be  one  evacuation  of  the  bowels  daily,  and  if  this  does 
not  occur  naturally,  an  enema  is  given. 

Bowel  Feeding. — In  conditions  of  collapse  in  any  illness,  in  coma 
and  certain  gastric  disorders  particularly,  sufficient  nutrition  cannot 
be  given  by  the  stomach.  When  such  a  condition  obtains,  regardless 
of  the  illness,  we  must  resort  to  colonic  feeding  (p.  83), 

Suppression  of  the  Urine. — Suppression  of  the  urine  is  not  an 
unusual  occurrence  in  pediatric  practice,  and  may  occur  in  a  wide 
range  of  diseases.  One  of  our  most  successful  means  of  combating 
this  condition  is  the  use  of  colonic  flushings  (p.  795). 

Pyrexia. — High  temperature  in  children,  regardless  of  the  nature 
of  the  illness,  is  to  be  managed  by  the  same  methods.  The  most  satis- 
factory in  my  hands  has  been  the  abstraction  of  heat  through  the 
means  of  hydrotherapy,  in  the  use  of  sponging  and  packs.  It  is  a 
popular  belief  among  laymen  that  cold  should  not  be  used  in  scarlet 
fever  or  measles  because  of  somfe  unfavorable  influences  exerted  on  the 
rash.  There  is  no  disease  of  childhood  with  temperature  in  which  the 
application  of  water  to  the  skin  does  harm.  I  use  spongings  and  packs 
in  scarlet  fever  exactly  the  same  as  in  pneumonia  or  typhoid  fever. 

When  is  elevation  of  the  temperature  to  be  interfered  with?  What 
are  the  indications  that  necessitate  interference?  When  we  have  a 
degree  of  temperature  that  causes  restlessness,  loss  of  sleep,  rapid 
heart  action,  with  resulting  loss  of  vitality — i.e.,  wasted  energy — then 
I  believe  that  means  for  reduction  should  be  instituted.  This  will  be 
necessary  in  some  patients  at  103°F. ;  in  others,  at  105°r.  In  other 
words,  we  should  be  governed  largely  by  the  effects  of  the  temperature 
upon  the  individual  and  not  by  the  reading  of  the  thermometer.  If 
sponging  is  employed,  I  use  one  part  alcohol  with  three  parts  of  water 
at  about  80°F.  The  skin  is  repeatedly  moistened  with  the  solution, 
which  is  allowed  to  evaporate.  In  some  patients  such  a  procedure  is 
soothing.  In  others  it  occasions  no  little  annoyance,  in  which  event 
it  must  not  be  used.  By  far  the  most  satisfactory  hydrotherapeutic 
procedure  consists  in  the  use  of  the  pack  (p.  777). 

Drugs. — Regardless  of  the  nature  of  the  disease,  a  full  dose  of  castor 
oil  is  of  benefit  at  the  beginning  of  the  illness. 

When  drugs  are  used,  it  is  essential  that  no  harm  shall  result. 

In  any  illness  in  a  child  one  requirement  is  to  keep  on  good  terms 
with  the  child's  digestive  tract.  In  our  medication  we  must  seek  to 
protect  the  stomach.  This  may  be  done  by  giving  much  of  the  medi- 
cation after  meals,  using  it  by  preference  in  capsule,  powder,  or  tablet; 
when  administered  between  meals,  it  is  to  be  given  well  diluted  with 


THE    SICK-ROOM  137 

water.  When  liquid  medication  is  necessary,  elixir  simplex  in  small 
amount  is  employed  as  a  flavoring  medium.  Useless  syrups  are  to  be 
avoided.  The  worst  possible  custom,  to  my  mind,  is  the  using  of  heavy- 
syrups  for  flavoring.  The  practice  of  giving  the  ammonia  salts  and 
ipecac,  usually  with  syrup  of  tolu,  to  a  child  with  severe  bronchitis  or 
bronchopneumonia  is  wretched;  and  this  is  putting  it  mildly. 

Stimulation. — I  have  two  criticisms  of  general  application  as  relates 
to  the  management  of  sick  children.  The  first  is  that  heart  stimu- 
lants are  used  too  early  and  in  too  large  dosage,  and  that  antipyretic 
measures  are  resorted  to  when  such  management  is  not  called  for. 
I  have  already  referred  to  the  latter  in  stating  that  a  child  should 
not  necessarily  have  antipyretic  measures  used  because  he  has  fever 
with  pneumonia,  typhoid,  or  scarlet  fever.  Neither  does  he  require 
stimulation  because  he  has  typhoid  or  scarlet  fever  or  pneumonia. 
Regardless  of  the  nature  of  the  illness,  our  choice  of  stimulants  is  very 
much  the  same,  and  our  reason  for  using  them  is  exactly  the  same — 
to  assist  a  heart  that  needs  help.  The  employment  of  heart  stimulants 
will  be  discussed  in  detail  under  proper  headings  in  the  different 
chapters. 

It  will  be  seen,  from  the  foregoing,  that  the  treatment  of  different 
diseases  of  children  has  many  features  in  common,  and  these  essentials 
must  be  appreciated  by  every  man  in  order  that  he  do  the  best  work 
in  treating  children. 

If  there  is  one  thing  that  has  been  impressed  upon  me  in  an  active 
life  of  twenty-eight  years  in  children's  work,  it  is  the  necessity  of  com- 
pleteness of  detail  in  our  management.  We  little  realize  how  sensitive 
the  sick  child  is,  how  all  nervous  effort,  all  untoward  influences,  cost 
something.  They  cost  energy  and  output  of  vitality  which  may  be 
sufficient  to  determine  the  issue  for  recovery  or  against  it.  Family 
cooperation  is  necessary  for  success,  and  will  be  best  obtained  through 
the  confidence  and  affection  engendered  by  thorough,  painstaking 
work  on  the  part  of  the  physician. 

THE  SICK-ROOM 

If  there  is  a  choice  of  rooms  for  the  patient,  the  size  of  the  room 
and  the  means  of  ventilation  are  important  points  to  be  considered  in 
the  selection.  During  cold  weather  a  room  with  southern  exposure, 
to  which  the  sun  has  free  access,  should  be  chosen.  During  the  hot 
months  of  summer,  however,  the  cooler  the  room,  the  better,  provided 
the  size  and  ventilation  are  satisfactory.  The  furnishings  should  be  of 
the  simplest,  only  those  articles  being  allowed  to  remain  which  are  re- 
quired for  the  patient.  So  many  of  the  ailments  of  childhood  are  of 
an  infectious  nature  that  only  such  articles  of  furniture  as  can  be 
washed  should  be  used.  Curtains,  hangings,  and  plush  furniture  have 
no  place  in  a  sick-room.  A  plain  wooden  floor  is  much  better  than  a 
carpeted  one.  Enameled  beds  and  plain  wooden  or  enameled  chairs 
and  tables  are  best,     A  painted  wall  is  much  better  than  a  papered  one. 


138  THE    PRACTICE    OF    PEDIATRICS 

A  fireplace  is  desirable  not  only  for  heating  purposes,  but  also  for  ven- 
tilation. The  successful  treatment  of  severe  illnesses  in  children  is 
often  determined  by  careful  attention  to  every  detail  in  the  care  of  the 
patient.  A  child  ill  in  a  dirty,  badly  ventilated,  overfurnished,  over- 
heated room  is  from  the  first  at  a  decided  disadvantage. 

The  Window-board. — A  convenient  and  simple  means  for  ven- 
tilating the  living-room,  sleeping-room,  or  sick-room  of  a  child  in 
cold  weather  is  what  is  known  as  the  window-board.  A  plain  inch 
board  is  sawed  the  width  of  the  window-frame  and  placed  under  the 
raised  window  in  the  lateral  frame  groove,  resting  upon  the  sill.  This 
raises  the  top  of  the  lower  sash  above  the  bottom  of  the  upper  one,  leav- 
ing a  space  between,  through  which  the  air  enters  with  the  current 
directed  upward.  The  board  may  be  of  any  width — four,  six,  or  eight 
inches.  A  width  of  six  inches  is  commonly  used.  There  are  various 
ventilating  devices  in  the  market.  Those  that  are  of  value  are  ex- 
pensive, and  their  effectiveness  over  the  simple  means  above  suggested 
does  not  warrant  the  expenditure. 

NECESSITY  OF  METHOD  IN  THE  MANAGEMENT  OF  CHILDREN 

During  my  work  in  pediatrics  among  all  types  and  classes  of  people, 
I  have  been  particularly  impressed  with  the  fact  that  some  children  are 
the  source  of  an  immense  amount  of  trouble,  while  others  of  no  better 
health  or  greater  strength  cause  very  little  anxiety  on  the  part  of  their 
parents.  Children  differ  greatly  as  regards  individual  traits  and  dispo- 
sition, but  these  can  be  fashioned  to  a  great  extent  by  proper  manage- 
ment. The  more  spirited  the  child,  the  greater  need  of  method  in  the 
care.  I  know  mothers  who  are  worn-out,  nervous  wrecks  for  no  other 
reason  than  a  lack  of  system  in  the  management  of  the  daily  life  of  their 
children.  Thoroughgoing,  conscientious  mothers  they  may  be,  but 
they  represent  that  large  number  of  mothers  who  have  never  been 
taught  that  certain  functions  and  duties  should  be  performed  only  at 
certain  definite  times  every  day.  This  subject  is  considered  not  from 
any  moral  standpoint  but  simply  because  of  its  bearing  upon  health. 

Beginning  at  birth,  the  baby  should  be  fed  or  nursed  at  definite 
times  and  at  no  others.  Sleeping  should  never  interfere  with  the  nurs- 
ing hours.  The  child  should  have  time  for  undisturbed  repose,  and 
a  midday  nap  should  be  insisted  upon  until  the  end  of  the  sixth  year. 
The  definite  time  for  meals,  with  properly  selected  food,  should  be 
continued  throughout  adolescence.  The  child  should  be  bathed 
at  a  certain  hour  and  aired  at  a  certain  hour.  "Runabouts"  should 
have  their  hours  for  play  and  should  retire  at  a  definite  time  every 
evening.  Such  a  regime  is  conducive  to  perfect  health,  consequently 
to  better  growth  and  development  and  to  a  stronger  manhood.  It  is 
idle  to  say  that  many  parents,  particularly  among  the  poor,  cannot  con- 
form to  such  requirements.  The  poor  are  just  as  anxious  to  do  the  best 
for  their  children  as  are  the  rich,  and  will  do  this  to  the  best  of  their 
ability  if  reasons  are  explained  to  them.     If  they  cannot  reach  the  ideal, 


TREATMENT    OF    THE    INDIVIDUAL  139 

they  will  attain  to  a  higher  degree  of  efficiency  by  striving.  The 
trouble  ordinarily  is  not  with  the  mother,  it  rests  more  with  the  medical 
adviser,  who  is  largely  responsible  for  the  ignorance  of  the  mother  and 
the  resulting  harm  to  her-  offspring. 

TREATMENT  OF  THE  INDIVIDUAL 

In  these  days  of  specialization,  in  associating  with  medical  men 
in  consultation  or  otherwise,  one  is  sometimes  impressed  with  the  fact 
that  there  is  a  tendency  for  the  patient,  the  individual,  to  be  lost  sight 
of,  to  be  overshadowed  by  the  immediate  disease  or  condition  from 
which  he  may  be  suffering.  In  children  the  success  of  the  treatment  in 
practically  every  chronic  ailment  depends  upon  the  vitality  of  the 
individual  patient  and  his  powers  of  resistance  as  a  whole,  to  a  much 
greater  degree  than  is  the  case  with  the  adult.  The  object  of  taking  up 
this  subject  is  not  to  be  unkindly  critical,  but  to  call  attention  to  one 
phase  of  the  management  which  is  not  sufficiently  appreciated  by 
many  who  have  to  deal  with  children  in  their  professional  work.  Not 
at  all  infrequently,  poorly  conditioned  children,  who  have  been  treated 
for  months  by  local  measures  for  a  skin  affection,  recover  without  any 
local  treatment  whatever  (other  than  an  attempt  perhaps  to  relieve 
the  itching)  when  their  lives  are  ordered  according  to  the  requirements 
of  the  growing  child  as  regards  nutrition,  bowel  evacuation,  sleep, 
suitable  clothing,  fresh  air,  and  rational  exercise.  I  have  seen  cases 
of  chronic  rhinitis  and  bronchitis  which  had  persisted  for  weeks  respond 
promptly  when  local  measures,  sprays  and  douches,  and  the  internal 
use  of  drugs  was  suspended  and  the  child's  life  was  directed  along  ra- 
tional lines.  Those  who  treat  tuberculosis  and  chronic  bone  diseases, 
chronic  otitis,  chorea,  and  hysteria,  are  to  be  reminded  that  their  work 
is  not  half  finished  when  they  have  directed  the  usual  daily  or  weekly 
routine  treatment.  In  these  chronic  ailments  it  is  folly  to  expect  what 
a  cure  really  means  (a  constructive  process)  on  a  destructive  diet  and 
improp>er  habits  of  life.  Children  possess  marked  recuperative  powers, 
and  the  rapidity  of  progress  toward  recovery  is  often  most  gratifying 
when  right  conditions  are  instituted  as  relates  to  these  fundamentals 
in  child  management;  viz.,  food,  sleep,  clothing,  and  bathing.  It  is  the 
height  of  folly  to  give  children  iron  for  anemia  and  allow  them  every 
form  of  indiscretion  in  diet.  It  should  always  be  remembered  that 
the  best  results  are  obtained  in  the  treatment  of  a  child,  whatever  the 
nature  of  his  illness,  when  he  has  a  child's  normal  existence,  and  it  is 
only  under  such  conditions  that  satisfactory  results  of  treatment  can 
be  expected. 


IIL  DISEASES  OF  THE  NEW-BORN 

PREMATURE  AND  CONGENITALLY  WEAK  INFANTS 

Comparatively  few  infants  born  before  the  completion  of  the 
twenty-eighth  week  of  pregnancy  survive  the  first  year.  Reported 
cases  of  survival  of  those  born  before  that  time  are  usually  unreliable, 
as  the  reports  seldom  follow  the  child  beyond  the  third  month.  The 
prognosis  is  influenced  by  the  factors  causing  the  premature  birth. 
If  syphilis  is  present,  the  child  may  survive  but  a  day  or  two.  Children 
whose  births  are  forced  because  of  kidney  disease  in  the  mother  do  not 
appear  to  do  as  well  as  others.  In  children's  institutions  I  have  treated 
a  large  number  of  premature  infants  and  have  had  anything  but 
brilliant  results  with  them.  They  not  infrequently  live  to  be  two, 
three,  or  four  months  of  age  or  older,  but  on  account  of  reduced  vitality 
they  readily  succumb  to  the  slightest  ailment,  a  mild  bronchitis  or 
fermentative  diarrhea  being  sufficient  to  terminate  their  existence. 

In  the  management  of  the  premature  and  delicate  newly  born  there 
are  four  points  to  be  considered — the  air  the  child  gets  to  breathe,  the 
nourishment,  the  maintenance  of  bodily  heat,  and  the  absence  of  infec- 
tion. It  is  also  to  be  remembered  that  we  are  dealing  with  an  unde- 
veloped body  which  is  not  ready  for  the  environment  in  which  it  is 
placed.  The  premature  baby  should  be  handled  only  when  necessary, 
and  then  in  the  gentlest  manner.  Bathing  is  often  best  omitted  for  the 
first  few  weeks,  oil  being  used  for  cleansing  purposes.  Because  of 
the  undeveloped  parenchyma  of  the  lungs  unusually  good  fresh  air  is 
required.  Because  of  the  undeveloped  heat-centers  the  body-heat 
of  these  infants  is  quickly  lost  and  must  be  maintained  by  artificial 
means.  The  stomach  is  small  and  the  digestive  processes  are  un- 
developed and  weak,  so  that  the  nourishment  should  be  of  the  most 
easily  assimilable  character. 

Artificial  Heat. — The  maintenance  of  heat  is  of  the  utmost  impor- 
tance. For  this  purpose  incubators  and  their  various  modifications 
have  been  used  from  time  to  time.  My  experience  with  incubators 
has  been  unsatisfactory.  They  may,  under  careful  watching,  main- 
tain an  even  temperature,  but  all  that  I  have  used  have  been  defective 
in  supplying  fresh  air  to  the  child.  My  incubator  babies  invariably 
have  done  badly.  The  padded  crib  with  the  child  wrapped  in  cotton 
and  surrounded  by  hot-water  bottles  is  a  safe  means  of  maintaining 
the  temperature.  A  thermometer  should  rest  between  the  cotton  and 
the  bed-clothing  as  a  guide  to  the  nurses  in  the  use  of  the  hot-water 
bottles.  Ordinarily  this  should  register  between  85°  and  90°F., 
depending  upon  the  temperature  of  the  child,  whose  rectal  temperature 
should  at  first  be  taken  frequently.  If  there  is  a  tendency  for  his 
temperature  to  be  greatly  reduced, — below  95°F., — more  external  heat 

140 


PREMATURE   AND    CONGENITALLY   WEAK   INFANTS 


141 


will  be  necessary  than  if  the  temperature  is  97°  or  98°F.  Various  beds 
and  devices  on  the  market  for  the  premature  are  rather  fanciful  affairs 
but  of  no  greater  service  than  methods  perhaps  more  crude.  Means 
and  methods  complicated  in  character  are  to  be  avoided  in  treating 
children  in  the  home. 

Room  Temperature.^ — The  temperature  of  the  room  should  be 
maintained  at  about  80°F.,  and  not  under  75°F. 

Fresh  Air. — Suitable  ventilation  may  be  secured  by  the  window- 
board  device  (p.  138). 

Absence  of  Infection. — Only  the  nurse  and  rarely  the  physician 
should  be  allowed  in  the  room.     Infection  of  any  nature  is  a  very 
serious   matter.     The  family  generally,  and  visitors 
always,  should  be  excluded  from  the  presence  of  the 
premature.  ,.^:  4 

Feeding  of  Premature  Infants. — Breast-milk  for     v*-  w 

premature  infants  born  under  twenty-eight  weeks  is  / 

almost  a  necessity,  and  should  always  be  procured  when  \,    , 

possible  for  all  premature  children.  The  mother,  with 
the  rarest  exception,  is  unable  to  supply  it,  so  that  a 
wet-nurse  should  be  secured.  In  selecting  a  wet-nurse 
for  a  premature  baby  it  is  advisable  to  take  the  wet- 
nurse's  baby  also,  as  the  premature  infant  may  not  be 
able  to  nurse,  or  if  he  nurses  he  will  not  take  all  the 
milk.  Pumping  the  breasts  of  a  wet-nurse  will  almost 
invariably  dry  them  up  if  her  own  baby  is  not  with  her 
to  furnish  the  necessary  stimulation  of  nursing.  Suffi- 
cient milk  may  be  removed  by  the  breast-pump  to 
supply  the  premature  infant  if  he  is  unable  to  nurse,  and 
the  wet-nurse's  baby  will  empty  the  breast.  For  pre- 
mature babies  who  refuse  the  breast  or  are  unable  to 
take  a  nipple,  the  Breck  feeder  (Fig.  9)  may  be  used 
as  a  means  of  giving  nourishment;  or  gavage  (p.  790) 
may  be  brought  into  use.  To  this  I  have  been  obliged 
to  resort  in  several  cases.  The  Breck  feeder  consists 
of  a  graduated  glass  tube,  narrowed  at  one  end.  Over 
this  end  is  placed  a  small  rubber  nipple,  the  other  end 
being  closed  by  a  flexible  rubber  cap.  Suction  on 
aided  and  encouraged  by  pressure  on  the  air-filled  cap. 
milk  proves  too  strong,  it  may  be  diluted  with  equal  parts  of  a  6  per 
cent,  sugar  solution,  from  one-half  to  one  ounce  of  the  mixture  being 
given  at  first  at  intervals  of  from  one  to  one  and  one-half  hours. 
Fourteen  to  fifteen  feedings  may  be  given  in  the  twenty-four  hours,  the 
amount  depending  upon  the  child's  digestive  ability.  If  human  milk 
is  not  obtainable,  whey  made  from  whole  milk  may  be  given,  the  nutri- 
tional equivalent  of  which  is  approximately  1  per  cent,  fat,  1  per  cent, 
proteid,  3.5  per  cent,  sugar;  or  one  ounce  of  gravity  cream  may  be  given 
with  one  ounce  of  milk-sugar  and  15  ounces  of  water,  which  affords  a 
nutritional  equivalent  of  1  per  cent,  fat,  5  per  cent,  sugar,  and  0.3  per 


/- 

-1 

_o 

N~ 

-3^ 

0- 

"^i 

-5 

[       — 

-0 

— -i 

Fig.        9.— The 
Breck  feeder. 

the   nipple  is 
If  the  breast- 


142 


THE    PRACTICE    OF    PEDIATRICS 


cent,  proteid.  Evaporated  milk  (p.  95)  is  a  useful  means  of  feeding 
in  these  cases.  The  food  strength  is  increased,  the  intervals  are  made 
longer,  and  the  feedings  larger,  as  the  patient  proves  able  to  assimilate 
the  food. 

The  premature  child  requires  unusual  advantages,  and  even  when 
but  one  month  premature,  rarely  "catches  up"  during  the  first  year, 
sometimes  not  for  two  or  three  years. 

CEPHALHEMATOMA 

These  tumors  are  usually  situated  at  the  site  of  the  caput  succedan- 
eum,  and  are  composed  of  blood.  Sometimes  pressure  of  the  forceps 
is  accountable  for  their  presence,  but  rarely  can  any  injury  be  found. 
During  a  long  and  tedious  labor  the  pressure  on  the  blood-vessels  of  the 
scalp  is  increased,  and  this  is  thought  to  be  an  active  cause  in  the  for- 
mation of  these  tumors.  Blood  changes  are  also  cited  as  a  possible 
etiologic  factor.  The  cause  cannot  be  ascribed  entirely  to  pressure 
against  the  presenting  part,  as  we  find  cephalhematomata  in  breech 
as  well  as  in  vertex  presentations.  The  hematomata  are  of  three  varie- 
ties, as  shown  by  Fig.  10. 

Double  cephalhematoma  may  exist. 


Fig.  10. — Varieties  of  cephalhematoma:  (a)  Between  scalp  and  periosteum;  (b) 
between  periosteum  and  skull;  (c)  between  skull  and  dura  mater. 

Pathology. — These  tumors  are  generally  situated  over  the  parietal 
bones.  The  scalp  may  show  small  hemorrhages  and  ecchymotic  areas. 
The  tumor  itself  is  composed  of  blood.  Soon  after  birth,  the  blood 
is  usually  in  a  fluid  state,  while  in  later  cases  coagulation  has  taken 
place.  The  tumor  may  be  infected  with  pus-forming  bacteria  and  an 
abscess  may  result. 

Symptoms. — Soon  after  birth — anywhere  from  the  first  to  the  fifth 
day — a  tumor  is  seen  occupying  a  position  generally  over  the  parietal 
bones.  It  is  soft,  gradually  increases  in  size  for  about  a  week,  and  then 
diminishes;  infrequently  a  ridge  develops  around  the  outer  border  of 
the  tumor,  giving  the  sensation  upon  pressure  of  a  depressed  fracture. 

During  the  latter  stage  of  the  tumor  a  crackling  sensation  will  be 
elicited  on  pressure  by  the  fingers.  There  is  no  accompanying  fever. 
The  child  shows  no  annoyance.  The  tumor  does  not  pulsate.  One 
must  be  careful  not  to  confound  this  condition  with  scalp  edema,  as 
seen  in  fracture  of  the  skull  after  severe  traumatism.  In  uncompli- 
cated cases  the  tumor  gradually  becomes  smaller  and  smaller,  until 
finally,  after  some  five  to  twelve  weeks,  it  disappears,  sometimes  leav- 
ing a  slightly  raised,  uneven,  bony  base. 


ICTERUS    NEONATORUM  143 

Diagnosis  (Differential). — Encephalocele  occurs  along  the  lines  of 
sutures  or  at  the  fontanels.  Pressure  may  cause  convulsions.  With 
movements  of  respiration,  the  swelling  may  vary  in  prominence. 

Hydrocephalus. — The  head  enlarges  as  a  whole,  showing  separated 
sutures  and  large  fontanels. 

Caput  Succedaneum. — Edematous,  does  not  fluctuate.  Disappears 
on  second  day. 

Depressed  Fracture  of  Skull. — Depression  exists  and  not  a  tumor. 

Prognosis. — In  the  uncomplicated  cases  the  prognosis  is  usually 
good.  The  prognosis  depends  upon  the  amount  of  injury  to  the  parts 
and  the  occurrence  of  any  infection.  Internal  cephalhematoma  with 
effusion  is  invariably  fatal. 

Treatment. — These  tumors  are  usually  absorbed  if  let  alone.  Care 
•should  be  exercised  that  no  injury  may  happen  to  them  during  handling 
the  infant.  No  dressing  is  necessary.  In  infected  cases,  where  the 
formation  of  an  abscess  has  occurred,  incision  and  drainage  are 
indicated. 

ICTERUS  NEONATORUM 

The  theories  relating  to  icterus  neonatorum  are  most  ingenious,  but 
as  all,  or  most  all,  are  based  on  speculation,  they  are,  as  a  result,  most 
unsatisfactory.  In  fact,  only  very  recently  has  there  been  much 
experimental  work  along  this  line. 

As  Stadelmann  stated  years  ago,  "Without  a  liver,  no  icterus," 
so  it  is  true  today  that  theories  excluding  the  liver  as  a  participant  are 
valueless.  The  forms  of  icterus  in  which  biliary  acids  are  demon- 
strated in  the  urine  must  be  attributed  to  the  resorption  of  bile  in 
the  liver.  In  icterus  neonatorum  the  presence  of  biliary  acids  has 
been  clearly  demonstrated  not  only  in  the  urine  (Holberstein) ,  but 
also  in  the  pericardial  fluid  (Hof meister) .  In  view  of  these  facts  it 
is  apparent  that  the  liver  must  play  the  all-important  part  in  tha 
production  of  icterus  because  it  is  certain  that  the  jaundice  cannot 
be  explained  by  hyperemia  or  capillary  hemorrhage.  The  so-called 
hematogenous  jaundice  deserves  more  consideration  in  the  light  of 
recent  experiments. 

Such  explanations  as  that  of  Franck,  assuming  a  plugging  of  the 
ductus  choledochus  by  means  of  mucus  and  cast-off  epithelium,  have 
been  disproved.  Of  no  further  moment  is  the  theory  of  Birch-Hirsch- 
feld,  who  assumed  an  edema  of  Glisson's  capsule^  none  of  these  assump- 
tions has  been  verified  by  other  observers.  By  anatomic  examina- 
tions of  the  liver  Bouchut's  hypothesis  of  a  hepatitis,  and  Epstein's 
theory  of  a  catarrh  of  all  ducts  of  the  liver,  have  been  demolished. 

To  the  hematogenic  factor,  which  has  been  strongly  supported  by 
Hofmeier,  Stadelmann,  and  others,  one  must  give  more  than  a  passing 
thought.  These  authors  assumed  that,  as  a  result  of  this  countless 
destruction  of  erythrocytes  during  the  first  days  after  birth,  a  polj^- 
cholia  resulted.  This  supposition  of  red-cell  destruction  has  been 
refuted,  the  cause  for  the  apparent  destruction  being  attributed  to 


144  THE    PEACTICE    OF    PEDIATRICS 

increase  in  the  blood-plasma.  Only  recently  Heiman  (Zeitschr.  f. 
Geburtsh.  u.  Gynak.,  1912)  has  supported  the  blood-destruction 
theory,  stating  that  an  actual  destruction  of  erythrocytes  does  occur. 
Assuming  this  later  observation  to  be  correct,  one  can  readily  see 
how  with  this  destruction  there  is  liberation  of  hemoglobin,  which  is 
taken  up  by  the  liver  and  transformed  into  bile-pigments.  It  is 
fm-ther  apparent  that  when  bile  is  thus  produced  in  excess  and  is  taken 
up  rapidly  by  the  liver  in  large  amounts,  the  bile  capillaries  are 
overtaxed  and  the  bile  cannot  be  rapidly  removed,  but  is  reabsorbed 
into  the  blood,  whereupon  choluria  develops.  If  this  excessive  pro- 
duction of  hemoglobin  increases  over  certain  limits,  the  "threshold 
of  the  kidney"  is  reached  and  the  hemoglobin  is  excreted  through  the 
kidneys,  thus  producing  a  hemoglobinuria  (Pearce,  Austin,  and 
Eisenberg,  Jour.  Exp.  Med.,  1912). 

The  theory  today,  which,  according  to  Finkelstein  (Lehrbuch  d. 
Sauglingkrankh.,  1905)  finds  greatest  acceptance,  is  that  of  Quincke. 
This  author  considers  a  patency  of  the  ductus  venosus  to  be  the  de- 
ciding factor;  by  a  persistency  of  the  lumen  of  this  duct  the  bile  passes 
directly  from  the  meconium  in  the  intestine  to  the  portal  vein,  and, 
circumventing  the  liver,  enters  the  inferior  vena  cava,  thus  producing 
the  icterus.  In  the  light  of  more  recent  research,  however,  this  duct 
has  been  found  open  as  late  as  the  fourth  week  of  life;  thus  if  this 
anatomic  fact  be  considered  a  criterion,  we  would  not  be  led  to  believe 
that  icterus  was  produced  by  the  patency  of  the  ductus  venosus,  for 
if  such  were  the  case,  icterus  would  be  a  phenomenon  not  of  the  first 
week,  but  of  the  first  month  of  life. 

According  to  Hess's  observation  with  the  duodenal  catheter,  bile 
is  excreted  into  the  intestine  rarely  during  the  first  twelve  hours  of  life, 
and  is  variable  during  the  subsequent  twenty-four  hours,  but  in  every 
one  of  his  cases  was  profuse  in  icterus  neonatorum.  In  many  of  his 
cases  of  marked  jaundice  the  secretion  was  so  profuse  as  to  overflow 
into  the  stomach,  which  was  demonstrated  by  the  introduction  of  the 
stomach-tube.  He  further  states  that  the  cause  of  this  condition  is 
not  at  present  definitely  proved;  however,  if  one  follows  the  principles 
of  the  physiology  of  the  secretion  of  bile,  one  can  assume,  what  seems 
to  be  probable,  that  the  icterus  is  due  to  an  increased  amount  of 
available  hemoglobin;  further,  that  some  bile  salts  are  taken  up  from 
the  intestine,  resulting  in  this  disintegration  of  blood-cells  and  a  conse- 
quent increase  of  bile.  Approaching  the  matter  from  another  view, 
one  can  readily  assume  that  the  diminutive  excretory  mechanism  of 
the  liver  at  this  stage  is  unable  to  cope  with  this  excess  of  bile,  which 
Hess  has  demonstrated,  and  that  a  congestion  of  the  bile  capillaries 
ensues,  as  is  shown  by  histologic  examinations,  and  icterus  results. 

Symptoms. — Probably  75  per  cent,  of  all  new-born  infants  show 
more  or  less  icterus  a  few  days  after  birth.  The  degree  of  jaundice 
varies  greatly.  In  comparatively  a  small  proportion  of  the  cases  the 
conjunctiva  becomes  deeply  involved. 

Infants  showing  marked  jaundice  may  lose  in  weight  as  a  result 


SCLEREMA  145 

of  this  condition.  The  jaundice  rarely  persists  longer  than  two 
weeks,  and  such  a  duration  is  seen  only  in  the  severe  cases.  In  the 
majority  of  the  cases  the  skin  is  clear  in  a  week  after  the  onset.  The 
urine  is  usually  free  from  bile-pigment.  The  stools  are  normal 
throughout. 

Treatment  is  not  required. 

SCLEREMA 

Sclerema  neonatorum  (Underwood's  disease)  is  a  rare  affection  of 
early  infancy  characterized  by  progressive  induration  of  the  skin. 

Etiology. — The  condition  may  be  present  at  birth;  the  majority 
of  the  cases  develop  before  the  tenth  day  of  life.  Nearly  all  the  re- 
ported cases  have  occurred  in  premature  infants  or  those  weakened 
by  preexisting  diarrhea  or  pneumonia.  Poor  hygienic  surroundings 
are  included  among  the  possible  predisposing  causes. 

Pathology. — Parrot  described  the  essential  process  as  a  drying-up 
and  thickening  of  the  skin,  associated  with  a  diminution  in  the  fatty 
elements  of  the  underlying  connective  tissue.  Langer  has  ascribed 
the  condition  to  a  solidification  of  the  fat  as  a  result  of  low  body- 
temperature,  a  phenomenon  more  readily  possible  in  the  new-born 
infant  than  in  the  older  subject,  because  of  the  peculiar  chemical 
composition  of  infant  fat  and  its  corresponding  property  of  solidifying 
at  a  relatively  high  temperature  (89.6°F.).  Other  authorities  have 
likened  the  cutaneous  changes  of  sclerema  to  those  occurring  in 
myxedema.  Mensi*  has  recently  distinguished  three  types  of 
sclerema,  depending  upon  the  degree  of  atrophy  in  the  skin.  In 
all  the  forms  atrophy  of  the  subcutaneous  connective  tissue  was  the 
chief  lesion.  Northrup  has  reported  a  case  in  which  microscopic 
examination  of  the  skin  revealed  nothing  abnormal. 

Symptoms. — The  chief  general  symptoms  comprise  progressive 
emaciation  and  asthenia,  subnormal  temperature,  and  failing  pulse 
and  respiration.  The  thickening  and  hardening  of  the  integument 
begin,  as  a  rule,  in  the  lower  extremities,  and  extend  upward  to  the 
trunk  and  face.  The  skin  assumes  a  yellowish,  waxy  hue,  and  later 
becomes  livid  and  perhaps  mottled.  It  is  extremely  tense,  does  not 
pit  on  pressure,  and  imparts  stiffness  to  the  motions  of  the  joints  and 
the  play  of  the  muscles  of  the  face.  Sucking  and  swallowing  may  be 
prevented.  The  infant  usually  dies  within  a  few  days,  but  excep- 
tionally may  survive  the  disease.  Dr.  Lotta  Meyers  f  has  recently 
reported  a  mild  case  in  a  female  infant,  without  the  usual  subnormal 
temperature,  death  occurring  on  the  twenty-fifth  day. 

Prognosis. — The  disease  is  usually,  but  not  invariably,  fatal. 

Diagnosis. — Scleroderma  and  scleredema,  the  only  conditions  re- 
sembling sclerema,  may  be  distinguished  by  the  fact  that  the  first 
has  not  been  noted  before  the  second  year  (Stelwagon),  while  sclere- 

*  Jour.  Cutaneous  Diseases,  October,   1912. 
t  Jour.  Cutaneous  Diseases,   1909. 
10 


146  THE    PRACTICE    OF    PEDIATRICS 

dema  is  seldom  generalized  or  accompanied  by  extreme  wasting,  and 
does  not  deprive  the  skin  of  its  color  or  elasticity  under  pressure. 

Treatment. — The  only  management  of  possible  value  consists  in 
the  maintenance  of  nutrition  and  bodily  heat.  In  suitable  cases  the 
incubator  may  be  used. 

SEPSIS  IN  THE  NEWLY  BORN 

The  newly  born  infant  is  peculiarly  susceptible  to  infections,  par- 
ticularly with  pyogenic  bacteria.  During  this  early  period  of  life  the 
normal  bodily  defenses  are  weakened.  Phagocytosis,  which  is  the 
great  protector  of  the  adult,  is  of  little  service  to  the  newly  born, 
who  display  little  resistance  against  any  bacterial  invasion. 

Etiology. — The  cause  of  sepsis  in  the  newly  born  is  the  entrance 
of  some  form  of  pathogenic  bacteria  into  the  body.  These  bacteria 
are  usually  of  the  streptococcus  or  the  staphylococcus  groups.  The 
pneumococcus,  the  colon  bacillus,  and  the  Bacillus  pyocyaneus  may 
also  cause  the  condition.  These  bacteria  have  been  shown  to  exist 
even  in  normal  breast  milk,  and  they  lurk  in  the  air  of  hospital  wards 
and  dwellings.  The  lochia  and  amniotic  fluid  of  the  mother  have 
been  shown  to  contain  them.  The  newly  born  infant  is  thus  sur- 
rounded on  all  sides  by  bacteria  ready  to  gain  admission  to  his  body. 
The  severity  of  a  given  case  of  sepsis  is  proportionate  to  the  degree  of 
virulence  of  the  bacteria  at  the  time  of  the  infection. 

Sources  of  Infection. — Infection  may  occur  through  the  mouth, 
which  is  probably  the  most  frequent  port  of  entry,  through  the  nose, 
the  skin,  the  rectum,  the  conjunctivge,  the  digestive  tract,  the  lungs, 
the  ears,  the  urethra,  the  umbilicus,  and,  in  girls,  the  vagina.  Almost 
any  portion  of  the  body  may  be  the  seat  of  the  infection.  It  is  rare, 
according  to  the  cases  upon  which  I  have  made  autopsies,  to  find  only 
one  organ  or  structure  affected.  Usually  two  or  more  portions  of  the 
body  are  involved  in  the  septic  process. 

Parts  Most  Frequently  Involved. — The  following  parts  of  the  body 
are  most  frequently  involved: 

Umbilicus. — The  seat  of  this  infection  is  usually  about,  or  in  the 
substance  of,  the  stump  of  the  umbilical  cord.  The  skin  and  tissues 
about  the  umbilicus  are  red,  indurated,  and  show  the  usual  signs  of 
septic  infiltration.  The  blood-vessels  of  the  cord  may  be  the  seat  of 
inflammation. 

Peritoneum. — Peritonitis  may  follow  the  extension  of  the  septic 
process  from  the  umbilical  cord  to  the  peritoneum,  and  under  such 
conditions  often  results  fatally.  The  peritonitis  may  be  local  or 
general. 

Joints. — The  joint  surfaces  and  membranes  may  be  the  seat  of 
suppuration,  or  osteomyelitis  may  occur.  Sometimes  the  epiphysis 
only  is  involved,  and  in  other  cases  the  shaft  of  the  bone  is  affected. 

Skin. — Single  or  multiple  abscesses  of  the  skin  and  underlying 
cellular  structures  are  also  liable  to  occur. 


SEPSIS    IN    THE    NEWLY   BORN  147 

Lungs. — Pneumonia,  usually  of  the  bronchial  variety,  may  develop 
as  a  septic  process,  with  only  vague  symptoms,  such  as  rapid  respira- 
tion and  cyanosis,  accompanying  the  fever. 

Intestines. — Diarrhea  accompanies  nearly  all  forms  of  sepsis  in  the 
newly  born.     Vomiting  may  occur. 

Brain. — The  meninges  are  rarely  attacked  by  the  septic  process, 
and  when  they  are  involved,  indefinite  symptoms  of  meningitis  are 
the  result. 

Heart. — A  septic  pericarditis  may  occur,  but  is  extremely  rare. 
Septic  endocarditis  is  more  common. 

Prophylaxis. — This  is  of  the  greatest  importance  in  guarding 
against  sepsis.  The  obstetrician's  hands  and  those  of  the  nurse 
should  be  just  as  sterile  when  handling  the  newly  born  infant  as  they 
are  in  caring  for  the  mother.  Asepsis  should  be  stringently  observed 
in  ligating  the  cord.  The  mother's  breasts  and  nipples  should  be 
cleansed  with  boric  acid  before  and  after  each  nursing. 

Prognosis. — Even  in  its  mildest  form,  septic  infection  of  the  newly 
born  is  very  serious.  When  structures  such  as  the  peritoneum,  brain, 
pericardium,  or  lungs  are  involved,  the  disease  is  invariably  fatal. 

The  red  cells  are  decreased  by  disintegration,  while  the  leukocytes 
are  increased. 

Treatment. — The  management  resolves  itself  into  relieving  the 
system  of  the  infection,  which  is  possible  when  its  seat  is  in  the  skin. 
When  there  is  multiple  abscess-formation,  incision  should  be  made 
and  followed  by  a  wet  dressing  of  a  saturated  solution  of  boric  acid, 
or,  if  the  area  is  not  too  large,  a  1:5000  solution  of  bichlorid.  If  the 
site  of  the  infection  is  at  the  umbilicus,  the  suppurating  surface  should 
be  thoroughly  cleansed  and  kept  covered  with  a  wet  dressing  of  1 :  5000 
bichlorid,  which  should  be  changed  at  least  every  two  hours.  If  there 
is  erysipelas,  an  ointment  composed  of  30  per  cent,  ichthyol  in  vaselin 
affords  the  best  dressing.  This  should  be  freshly  applied  every  four 
hours.  The  septic  infant,  whether  the  infection  is  mild  or  severe, 
usually  nurses  very  poorly.  Often  both  breast  and  bottle  are  re- 
fused. When  a  sufficient  amount  of  fluid  is  not  taken,  plain  boiled 
water  or  sugar- water,  5  per  cent.,  or  completely  peptonized  skimmed 
milk,  may  be  given  by  gavage.  If  fluids  are  not  given,  the  child  is 
very  apt  to  develop  inanition  fever,  which,  added  to  the  infection, 
makes  a  serious  condition  more  serious.  From  two  to  four  ounces  of 
a  normal  salt  solution  used  lukewarm,  injected  into  the  descending 
colon  through  a  catheter,  will  often  be  retained,  with  beneficial  results. 
It  should  not  be  repeated  oftener  than  once  in  six  hours. 

Medication  other  than  small  doses  of  alcohol — five  drops  of  brandy, 
well  diluted,  every  hour,  if  necessary — has  been  without  avail  in  my 
cases.  The  prognosis  at  best  is  very  grave,  although  cases  in  which 
the  vital  organs  are  not  involved  occasionally  recover. 

Illustrative  Case. — An  unusual  instance  of  infection  which  ended  in  recovery- 
occurred  in  my  private  practice.  The  child  had  no  fever,  but  lost  rapidly  in  weight 
and  experienced  marked  prostration.  The  skin  took  on  a  greenish  hue,  and  we 
were  at  a  loss  to  discover  the  cause  of  the  illness.     The  infection  was  suspected,  but 


148  THE    PRACTICE    OF    PEDIATRICS 

no  portal  of  entry  could  be  found;  neither  could  we  find  any  localized  process 
until  the  nurse  discovered  that  the  umbilicus  and  the  surrounding  skin  were  bathed 
in  pus.  The  umbilicus  had  apparently  healed  without  any  indication  of  local 
trouble.  Investigation  showed,  however,  that  the  infection  had  entered  at  this 
site,  and,  extending  along  the  vein  or  artery,  had  become  pocketed  and  formed  an 
abscess  IJ^  inches  deep.  Enlarging  the  opening  at  the  umbilicus  and  establishing 
free  drainage  were  followed  by  a  gradual  closure  of  the  abscess  cavity  and  recovery. 

ASPHYXIA  NEONATORUM 

Asphyxia  neonatorum  is  a  condition  of  the  newly  born  of  grave 
menace  to  the  child's  life,  and  requiring  the  most  active  and  intelligent 
treatment. 

Etiology. — -The  asphyxia  is  due  to  a  subaeration  of  the  blood  of  the 
fetus  or  infant.  This  subaeration  may  be  caused  by  anything  which 
tends  to  retard  the  interchange  of  carbon  dioxid  and  oxygen  in  the 
fetal  circulation,  and  may  take  place  before  or  during  labor.  As  a 
result  of  the  interference  of  the  placental  interchange  of  gases,  the 
products  of  metabolism  in  the  fetus  stimulate  the  inactive  respiratory 
center.  This  at  first  causes  respiratory  efforts,  with  the  aspiration  of 
more  or  less  air,  meconium,  or  amniotic  fluid,  according  to  the  infant's 
position  in  the  parturient  tract,  and  later,  if  the  subaeration  is  not 
relieved  by  the  quick  extraction  of  the  child,  allowing  access  of  air 
for  the  expansion  of  the  lungs,  produces  depression  of  the  respiratory 
center. 

The  causes  operating  antepartum  include  any  conditions  which 
interfere  with  the  oxidation  of  the  mother's  blood,  such  as  heart  or 
respiratory  disease  in  the  mother,  hemorrhage,  or  eclampsia;  any- 
thing which  causes  a  premature  separation  of  the  placenta,  such  as 
placenta  preevia  or  accidental  hemorrhage;  and  anything  which  causes 
pressure  upon  the  cord  or  the  child,  as  the  premature  rupture  of  the 
membranes,  maternal  convulsions,  or  tetanic  contractions  of  the  uterus. 
During  labor,  likewise,  pressure  upon  the  cord  from  prolapse  or  mal- 
position, pressure  upon  the  head,  with  or  without  meningeal  hemor- 
rhage, or  separation  of  the  placenta  before  the  delivery  of  the  head, 
as  in  "vaginal  birth,"  may  cause  asphyxia.  Prematurity  and  con- 
genital disability  or  defects,  such  as  atresia  of  the  pulmonary  artery, 
may  be  causative  factors  inherent  in  the  child. 

Pathology. — The  pathologic  changes  are  due  to  the  venous  en- 
gorgement and  the  aspiration  of  fluids.  The  right  heart  is  distended 
with  fluid  blood  or  soft  clots;  the  vena  cava,  the  large  thoracic  veins, 
the  sinuses  of  the  dura,  and  the  hepatic  vessels  are  also  distended. 
The  pulmonary  vessels  may  be  distended  or  not,  according  to  the 
extent  and  degree  of  respiratory  efforts  made.  As  a  result  of  aspira- 
tion the  trachea  and  bronchi  may  be  quite  filled  with  mucus,  meconium, 
blood,  and  amniotic  fluid.  The  lungs  may  show  areas  of  atelectasis, 
or  may  be  partially  aerated  and  intensely  engorged.  The  liver  is 
dark  bluish  in  color.  There  may  be  punctate  hemorrhages  in  various 
parts  of  the  body. 

Symptomatology. — It  has  been  customary  to  divide  the  symptoms 
of  asphyxia  neonatorum   into  two  groups,  according  to  the  color  of 


ASPHYXIA    NEONATORUM  149 

the  child  and  the  state  of  the  musculature — asphyxia  livida  and 
asphyxia  palljda.  They  are  essentially  the  same  condition,  asphyxia 
pallida  being  the  terminal  stage  of  asphyxia  livida,  and  a  case  of 
asphyxia  pallida  (if  recovery  takes  place)  passing  through  the  stage 
of  asphyxia  livida. 

Asphyxia  Livida. — The  child  who  is  in  the  condition  of  asphyxia 
livida  presents  a  characteristic  appearance:  the  skin  is  blue  or  livid, 
the  mucous  membranes  are  dusky,  the  sclerotics  are  congested.  The 
pupils  are  equal  and  react,  and  the  position  of  the  eyes  is  normal.  The 
respiratory  efforts  are  infrequent  and  gasping.  The  heart  action  is 
rapid  and  tumultuous,  and  the  heart-sounds  are  loud.  The  umbilical 
vessels  are  engorged  and  pulsate  forcibly.  The  muscles  are  every- 
where tense;  the  reflexes  are  active;  the  cutaneous  sensibility  is  pre- 
served, and  the  skin  is  warm.  The  anal  sphincter  functionates.  The 
condition  is  a  sthenic  one,  and  analogous  to  the  convulsive  stage  of 
ordinary  asphyxia. 

A  child  in  this  form  of  asphyxia  may  recover  by  the  respirations 
becoming  more  frequent,  the  color  changing  to  normal  hue,  the  over- 
acting heart  quieting  down,  and  a  normal  condition  appearing;  or  the 
condition  may  pass  by  gradual  stages  into  the  other  form,  asphyxia 
pallida.  The  degree  of  asphyxia  in  the  beginning  may  be  midway 
between  the  two  types. 

Asphyxia  Pallida. — The  child  with  asphyxia  pallida  is  limp  and 
pale.  The  entire  musculature  is  relaxed,  the  lower  jaw  and  head  hang 
down,  and  the  limbs  drop.  Respiratory  efforts  are  absent  altogether 
or  so  slight  as  to  escape  detection.  The  cord  is  flabby,  the  pulsa- 
tion is  inappreciable,  or  can  be  hardly  felt,  and  the  cord,  when  cut, 
bleeds  very  little.  The  heart-sounds  are  usually  faintly  heard  and 
may  be  slow  or  rapid.  The  sphincter  ani  is  relaxed  and  allows  the 
passage  of  meconium.  The  subcutaneous  sensibility  and  reflexes 
are  abolished.  The  temperature  is  lowered  one  to  three  degrees.  In 
this  form  spontaneous  recovery  almost  never  takes  place. 

Diagnosis. — The  diagnosis  of  asphyxia  neonatorum  may  be  made 
intrapartum  by  detecting  the  slowing  of  a  previously  well-acting  fetal 
heart,  the  passage  of  meconium  in  the  liquor  amnii,  the  trembling  of  the 
head  in  a  breech  extraction,  and  the  so-called  vaginal  cry.  Post- 
partum, the  condition  is  recognized  by  the  symptoms  as  detailed. 
Asphyxia  neonatorum  must  occasionally  be  differentiated  from  menin- 
geal hemorrhage,  which  is  likewise  caused  by  prolonged  labor  and 
which  often  occurs  with  asphyxia.  When  the  hemorrhage  is  large,  it 
can  be  readily  recognized  by  the  bulging,  tense  fontanel  and  by  the  ' 
existence  of  coma  and  possibly  paralysis.  Hemorrhage  may  affect 
the  respiratory  center,  in  which  event  the  two  conditions  are  really 
one. 

Prognosis. — The  prognosis  without  treatment  is  always  bad.  In 
cases  of  asphyxia  pallida  spontaneous  recovery  is  rare,  and  even  with 
the  most  active  treatment  many  do  not  survive.  After  apparent  recov- 
ery death  may  yet  occur  from  weakness  or  injuries  incidental  to  the 


150  THE    PRACTICE    OF    PEDIATRICS 

initial  asphyxia.  Idiocy  and  feeble-mindedness  may  often  be  due  to 
the  same  cause. 

Prophylaxis. — In  the  treatment  of  asphyxia,  prevention  belongs  to 
the  province  of  the  obstetrician.  Everything  should  be  done  to  avoid 
any  of  the  maternal  causative  factors,  and  in  the  conduct  of  labor  itself 
the  aim  of  the  physician  should  be  to  deliver  the  child  as  quickly  as  is 
compatible  with  safety,  not  hesitating  to  apply  low  or  medium  forceps 
in  preference  to  a  long  and  tedious  second  stage. 

Treatment. — The  active  treatment  is  directed  toward  maintenance 
of  body  heat  and  stimulation  of  respiration.  The  child,  as  soon  as 
born,  should  be  wrapped  up,  and  if  asphyxia  exists,  active  treatment 
should  immediately  be  instituted.  The  mouth  and  throat  should  be 
wiped  free  of  the  mucus,  which  will  almost  invariably  be  found,  by 
means  of  the  index-finger  well  wrapped  with  absorbent  cotton  or 
sterile  gauze.  It  may  be  necessary  to  suck  out  the  secretions  by  means 
of  a  catheter  and  a  glass  tube  with  a  bulb  on  it  to  prevent  the  secretions 
from  the  mouth  of  the  physician  or  nurse  getting  into  the  child's 
pharynx.  This  will  be  especially  necessary  when,  as  the  result  of 
respiratory  efforts  during  the  passage  of  the  head  through  the  pelvis, 
much  amniotic  fluid,  mucus,  etc.,  may  have  been  aspirated.  It  is  not 
advisable,  however,  to  attempt  much  instrumentation  of  the  larynx, 
but  to  rely  on  Schultze's  method  for  bringing  out  aspirated  secretions. 
The  respiratory  center  must  be  stimulated.  This  may  be  attempted, 
depending  upon  the  severity  of  the  asphyxia,  by  tickling  the  nares,  by 
administering  the  fumes  of  ammonia,  by  spanking  ("flagellating  the 
buttocks,"  Koplik),  by  the  alternate  use  of  hot  (110°r.)  and  cold 
(60°F.)  baths,  the  child  being  transferred  rapidly  from  one  to  the 
other,  always  ending  with  the  hot  one,  or  by  combining  with  these  one 
of  the  various  methods  of  artificial  respiration,  of  which  the  sim- 
plest is  perhaps  the  mouth-to-mouth  method.  Sometimes  bleeding  of 
the  cord  will  relieve  the  intense  congestion  of  the  right  heart  and  large 
thoracic  veins,  and  allow  the  heart  to  restore  the  circulation  and  relieve 
the  respiratory  center.  The  most  commonly  used  methods  of  artificial 
respiration  are  those  of  Laborde,  Dew,  and  Schultze. 

The  Lahorde  method  consists  in  making  rhythmic  traction  on  the 
tongue,  from  12  to  14  times  a  minute,  which  it  is  claimed  excites  res- 
piration. 

The  Dew  method  consists  in  grasping  the  infant  by  the  back  of  the 
neck  with  one  hand  and  by  the  knees  with  the  other.  The  upper  and 
lower  portions  of  the  child  are  then  approximated  by  a  flexion  of  the 
thorax  on  the  abdomen,  and  the  reverse  movement,  extension,  is  next 
effected.  Alternate  flexion  and  extension  are  thus  practised  15  to  20 
times  a  minute. 

Schultze's  method  is  described  by  him  and  quoted  by  Edgar  as  fol- 
lows: "The  child  lying  upon  its  back  is  grasped  by  the  shoulders,  the 
open  hand  having  been  slipped  beneath  the  head.  The  last  three  fin- 
gers remain  extended  in  contact  with  the  back,  while  each  index-finger 
is  inserted  into  an  axilla,  the  thumbs  lying  upon  and  in  front  of  the 


ASPHYXIA    NEONATORUM  151 

shoulders.  When  the  child  thus  held  is  allowed  to  hang  suspended, 
its  entire  weight  rests  upon  the  two  fingers  in  the  arm-pits.  It  is  now 
swung  forward  and  upward,  the  operator's  hands  going  to  the  height  of 
his  own  head;  the  pelvic  end  of  the  child  rises  above  its  head  and  falls 
slowly  toward  the  operator  by  its  own  weight,  flexion  occurring  in  the 
lumbar  region.  The  thumbs  in  front  of  the  shoulders  compress  the 
chest,  while  the  hyperflexed  lumbar  vertebrae  and  pelvis  compress  the 
abdomen,  and  through  it  the  thorax;  finally  the  last  three  fingers  on 
each  side  compress  the  thorax  laterally.  As  a  result  of  this  manoeuver, 
when  properly  done,  aspirated  secretions  flow  abundantly  from  the 
mouth.  The  distended  heart  also  feels  the  compression  which  forces 
the  blood  into  the  arteries.  The  child  is  now  swung  back  into  its  origi- 
nal position  and  supported  entirely  by  the  fingers  in  the  axilla.  The 
compression  of  the  thumbs  and  last  three  fingers  is  removed.  The 
downward  swing  elevates  the  sternum  and  ribs,  while  gravitation  and 
the  traction  of  the  intestines  depress  the  diaphragm.  It  is  often  pos- 
sible to  hear  the  air  rush  into  the  infant's  glottis  as  it  reaches  the  original 
position,  although  this  can  occur  in  a  cadaver.  The  amplification  of 
the  thorax  lowers  the  intracardiac  pressure.  The  child  should  be 
swung  up  and  down  10  times  for  the  space  of  a  minute.  The  effects  of 
the  manoeuver  should  be  as  follows:  the  heart-beat  increases  in  fre- 
quency, the  cadaveric  pallor  of  the  skin  becomes  replaced  by  a  rosy  hue, 
and  the  muscular  tonus  appears.  The  child  is  then  placed  in  a  warm 
bath  and  watched.  If  the  inspirations  are  superficial,  a  momentary 
dip  in  cold  water  is  indicated.  If  the  heart-action  becomes  poor,  the 
child  should  be  swung  again.  If  prolonged  swinging  becomes  neces- 
sary, the  root  of  the  tongue  should  be  compressed  forward  in  order  to 
raise  the  epiglottis  and  permit  the  removal  of  secretions  with  the  fin- 
gers. In  premature  children  the  thoracic  walls  are  often  too  soft  to 
benefit  by  the  compression  of  the  fingers.  In  these  cases  insufilation 
of  air  should  be  practised." 

In  the  cases  of  asphyxia  livida,  where  the  reflexes  and  the  cuta- 
neous sensibility  are  abolished,  all  attention  should  be  devoted  to  the 
general  stimulation  of  the  child.  The  cord  should  be  cut  at  once;  it 
will  often  not  bleed  at  all.  The  air-passages  should  be  freed  from  ac- 
cumulated secretions  as  before.  The  child  should  be  put  into  a  warm 
bath  and  artificial  respiration  attempted  by  the  mouth-to-mouth 
method  or  Laborde's  method.  Rectal  injection  of  one  to  two  ounces 
of  coffee  infusion,  or  hypodermic  injection  of  3'^oo  grain  of  strychnin, 
may  be  given  and  repeated  in  half  an  hour. 

Signs  of  recovery  in  asphyxia  pallida  are  a  return  of  the  cutaneous 
sensibility,  a  reappearance  of  the  reflexes,  an  increase  of  the  tonicity 
of  the  muscles,  one  or  more  respirations,  or  a  gradually  increasing 
cyanosis  and  venous  engorgement  approximating  the  condition  of  as- 
phyxia livida.  Finally,  a  gradual  change  to  normal  hue,  with  restored 
respiration  and  relaxation,  indicates  recovery. 

A  strict  watch  must  be  kept  over  the  child  for  several  days,  for  re- 


152  THE    PRACTICE    OF    PEDIATRICS 

lapses  are  common.     Oxygen  must  be  at  hand,  and  all  apparatus  ready 
for  a  resumption  of  the  active  treatment  at  any  moment. 

DELAYED  ASPHYXIA 

Asphyxia  may  occur  after  birth  in  a  child  who  has  had  an  unevent- 
ful delivery  and  who  appears  quite  normal  when  born. 

Etiology. — This  form  of  asphyxia  is  due  to  some  cause  interfering 
with  the  proper  continuance  of  the  respiratory  function.  Develop- 
mental anomalies,  such  as  defects  of  the  nervous  system,  the  heart, 
the  diaphragm,  the  thoracic  walls,  or  the  lungs,  or  the  general  weakness 
of  prematurity,  may  be  the  cause.  Compression  of  the  trachea  by 
enlarged  thyroids,  and  possibly  by  thymus  glands,  has  been  reported. 
Syphilitic  pneumonia  or  bilateral  pleuritic  effusions  or  an  enlarged  liver 
may  be  the  etiologic  factors. 

Symptoms. — The  clinical  symptoms  correspond  closely  to  those  of 
ordinary  asphyxia.  The  infant  makes  very  feeble  respiratory  efforts 
or  none  at  all;  the  heart  beats  with  considerable  strength,  becoming 
weak  as  the  asphyxia  continues  and  approaches  the  stage  of  flaccidity. 

Prognosis. — The  prognosis  is  dependent  upon  the  severity  of  the 
asphyxia  and  the  removability  of  the  cause. 

Treatment. — Treatment  is  that  of  any  form  of  asphyxia,  and  con- 
sists in  stimulating  respiration  and  circulation  and  the  removal  of 
the  cause.  Asphyxia  due  to  prematurity  should  be  treated  according 
to  the  methods  advised  for  caring  for  premature  babies  (p.  141). 

ATELECTASIS 

Atelectasis  may  be  present  in  the  newly  born  who  come  into  the 
world  asphyxiated,  and  it  is  not  infrequently  seen  when  there  has  been 
a  prolonged,  difficult  delivery.  Atelectasis  may  be  the  result  of  weak- 
ness, pure  and  simple,  and  is  not  of  unusual  occurrence  in  the  pre- 
mature. For  some  reason  there  is  a  failure  or  inability  to  dilate  the 
air-vesicles.  I  have  seen  sudden  collapse  occur  in  marantic  infants, 
the  child  dying  in  a  few  moments  with  cyanosis  and  orthopnea,  the 
autopsy  proving  the  diagnosis  of  atelectasis.  The  condition  may 
be  produced  also  through  compression  of  the  lung  with  exudation  in 
pleurisy,  or  by  the  obstruction  of  a  bronchus  with  mucus.  The  most 
dangerous  types  are  those  which  are  present  in  the  newly  born  and 
which  occur  in  the  weakly  during  early  life.  The  warning  symptoms 
are  usually  cyanosis  and  rapid  superficial  breathing,  with  or  without 
convulsions. 

Treatment. — The  management  of  atelectasis,  both  in  the  newly 
born,  who  come  into  the  world  asphyxiated  because  of  prolonged  diffi- 
cult delivery,  and  in  those  in  whom  the  condition  is  the  result  of  weak- 
ness, consists  in  making  the  child  cry  lustily.  If  auscultation  over  the 
lower  lobes  posteriorly  does  not  show  free  vesicular  breathing,  the 
child  should  be  made  to  cry  every  day,  either  by  spanking  or  by  plung- 
ing him  first  into  water  at  110°F.  and  again  into  cold  water  at  60°F., 


CONGENITAL    ABSENCE    OF   BILE-DUCTS  153 

our  object  being  to  induce  vigorous  crying  and  thus  dilate  the  air- 
vesicles.  A  recent  case  made  satisfactory  improvement  by  receiving 
oxygen  inhalations  for  one  minute  out  of  every  fifteen,  with  stimulation 
of  various  kinds  to  induce  crying.  Atelectasis  from  obstruction  of  a 
bronchus  or  from  compression  is  usually  readily  relieved  when  the 
source  of  the  trouble  is  removed.  In  out-patient  work  we  occasionally 
see  marantic  young  infants  in  whom  there  is  an  involvement  of  a  con- 
siderable area  of  one  of  the  lower  lobes  posteriorly  without  any  sign 
whatever  of  discomfort.  The  process  of  resolution  in  these  cases  pro- 
gresses from  the  periphery  toward  the  center  and  is  very  slow.  The 
condition  is  probably  of  much  more  frequent  occurrence  than  is  gen- 
erally supposed,  if  we  are  to  judge  from  the  autopsy  findings  in  cases 
of  young  infants,  particularly  in  institutions. 

AMYOTONIA  CONGENITA  (OPPENHEIM'S  DISEASE) 

Amyotonia  congenita  was  described  by  Oppenheim  in  1900.  It 
is  characterized  by  a  general  muscular  weakness,  observed  soon  after 
birth,  which  may  be  a  complete  flaccid  paralysis  of  the  extremities. 
Paralysis  of  the  lower  extremities  is  often  complete,  but  in  the  upper, 
some  movement  can  as  a  rule,  be  obtained.  The  diaphragm  and  facial 
muscles  escape.  The  intercostal  and  neck  muscles  are  often  affected. 
The  cause  is  not  known. 

Pathology. — In  some  cases  there  is  degeneration  in  the  anterior 
horns  of  the  spinal  cord,  but  this  is  not  constant.  The  chief  lesions 
are  in  the  muscles  which  show  atrophy  and  degeneration. 

Symptoms. — ^The  cases  show  all  degrees  of  severity,  from  a  slight 
weakness  which  passes  entirely  unnoticed  to  a  well-marked  disability 
which  represents  a  flaccid  paralysis,  in  which  the  child  is  perfectly 
helpless.  In  the  latter  cases  the  knee-jerks  are  absent  and  the  elec- 
trical reactions  are  very  weak.  If  the  intercostals  are  involved,  the 
respirations  may  be  labored  and  diaphragmatic  in  character.  Choking 
attacks  occur  from  collection  of  secretions  in  the  pharynx.  There  is 
no  sensory  involvement  or  sphincter  disturbances.  .  Mentality  is 
normal. 

Prognosis. — ^The  severe  forms  often  end  in  death  from  some  in- 
tercurrent infection,  such  as  broncho-pneumonia.  The  mild  forms 
may  continue  for  years  and  show  some  improvement. 

Treatment. — Massage  and  electrical  treatment  may  be  given  but 
they  do  not  offer  much  hope. 

CONGENITAL  ABSENCE  OF  BILE-DUCTS 

This  malformation  is  of  very  rare  occurrence.  The  first  symptom, 
a  rapidly  developing  jaundice,  appears  not  later  than  the  third  day 
after  birth.  The  jaundice  increases  rapidly,  and  in  a  few  days  is  in- 
tense. In  a  case  which  I  saw  at  the  fifth  month  the  skin  was  of  a  deep, 
greenish-yellow  color,  the  conjunctiva  was  deep  yellow,  and  the  mucous 


154  THE    PRACTICE    OF    PEDIATRICS 

membranes  of  the  lips  and  buccal  cavity  were  involved  in  the  discolora- 
tion. In  all  cases  after  the  passage  of  the  meconium  the  stools  become 
clay-colored  and  so  remain.  The  urine  is  of  a  deep  brown  color.  The 
liver  is  always  enlarged. 

Death  usually  results  from  inanition  before  the  third  month.  In 
one  case  the  child  died  at  the  ninth  month.  In  two  cases  the  com- 
mon duct  was  represented  by  a  fibrous  cord ;  in  another  there  was  an 
entire  absence  of  the  common  duct. 

Holmes*  gives  an  extensive  review  of  the  literature  covering  over 
100  cases,  with  89  diagrammatic  representations  of  the  different  de- 
formities.    These  diagrams  show  a  wide  range  of  deformities. 

Diagnosis. — In  icterus  neonatorum  of  the  familiar  type  bile  is  never 
absent  from  the  stools,  even  though  there  is  a  marked  degree  of  jaun- 
dice, and  the  skin  begins  to  clear  in  the  second  week.  A  continuation 
of  the  jaundice  without  abatement  after  this  time  is  suggestive  of  con- 
genital obstruction  of  the  ducts,  and  an  examination  of  the  stools  de- 
termines the  condition. 

;  UMBILICAL  GRANULOMA 

A  granuloma  at  the  umbilicus  consists  of  a  reddish,  secreting  mass 
of  granulations  involving  the  umbilical  stump.  It  may  vary  in  size 
from  the  head  of  a  pin  to  a  pea.  Granulomata  usually  occur  in  cases 
in  which  the  care  of  the  cord  has  been  neglected.  In  out-patient  work 
they  are  very  frequently  seen,  and  occur  usually  in  children  who  have 
been  delivered  by  mid  wives.  The  mother  brings  the  child  to  the  dis- 
pensary with  the  story  that  the  navel  will  not  heal. 

The  granulations  are  very  vascular  and  bleed  readily. 

Treatment. — After  thoroughly  cleansing  the  parts,  one  or  more  ap- 
plications of  a  50  per  cent,  nitrate  of  silver  solution,  followed  by  the 
free  use  of  an  absorbent  dusting-powder,  soon  produces  a  normal  cica- 
trix.    A  powder  of  the  following  composition  is  recommended: 

I^  Acidi  salicj^lici gr.  xv 

Acidi  borici gr.  xxv 

Pulveris  zinci  oxidi 

Pulveris  amyli aa  5  j 

The  powder  should  be  applied  very  freely  at  two-hour  intervals 
during  the  day,  or  at  least  often  enough  to  keep  the  wound  dry. 

UMBILICAL  POLYP 

An  umbilical  polyp  is  usually  the  result  of  an  overgrowth  or  an 
outgrowth  of  a  neglected  granuloma.  The  mass,  which  may  vary  in 
size  from  a  flaxseed  to  a  pea,  is  reddened,  moist,  and  usually  bathed  in 
a  viscid,  mucopurulent  secretion.  There  is  often  considerable  excoria- 
tion of  the  skin  about  the  umbilical  opening.  Sometimes  the  mass  is 
so  small  that  it  is  hidden  by  the  overlapping  folds  of  skin  and  its  pres- 

*Amer.  Journal  Diseases  of  Children,  vol.  xi,  No.  vi. 


MASTITIS    IN    THE    NEWLY   BORN  155 

€nce  would  not  be  suspected  but  for  the  secretion  which  keeps  the 
parts  moist.     The  polyps  are  very  vascular. 

Treatment. — Cutting  the  pedicle  and  applying  nitrate  of  silver  or 
carbolic  acid  is  not  a  safe  procedure.  I  have  known  severe  hemorrhage 
to  follow  such  treatment.  About  twenty  five  years  ago  I  was  obliged  to 
sit  for  three  hours  by  the  side  of  a  crying,  wriggling  child  making  pressure 
on  the  cut  stump  of  an  umbilical  polyp  after  a  colleague  had  cut  the 
pedicle.  In  no  other  way  could  the  hemorrhage  be  controlled.  The 
best  management  in  these  cases  is  to  ligate  the  pedicle  and  allow  the 
polyp  to  wither  and  drop  off.  The  powder  referred  to  under  the  head 
of  Granuloma  should  be  applied  after  the  ligature  is  fixed,  and  reap- 
plied frequently  before  and  after  the  polyp  has  dropped  off,  until  the 
wound  is  cicatrized  and  dry. 

MASTITIS  IN  THE  NEWLY  BORN 

Inflammation  of  the  breasts  in  the  newly  born,  both  in  the  male 
and  in  the  female,  is  seen  with  considerable  frequency  in  hospital  prac- 
tice. The  mammary  glands  may  be  acutely  tender  and  swollen  to 
several  times  their  normal  size.  These  glands  in  young  infants  should 
not  be  pressed  nor  manipulated  in  any  way  more  than  is  required  for 
cleanliness.  Not  a  few  of  my  out-patient  cases  of  mastitis  have  been 
due  to  the  attempts  of  the  midwife  to  express  the  milk  from  the  breasts. 
The  cases  are  explained  by  the  fact  that  the  opening  of  the  nipple  is 
large  and  the  gland  readily  becomes  infected  from  unwashed  hands  or 
unclean  wearing  apparel. 

Treatment. — My  cases  have  usually  responded  well  to  the  appli- 
cation of  ichthyol — 25  per  cent,  in  oxid  of  zinc,  U.  S.  P.  The  ointment 
is  spread  generously  upon  old  hnen  which  has  been  boiled  and  dried, 
and  is  then  gently  bound  upon  the  inflamed  gland.  Over  this  is  placed 
oiled  silk  to  protect  the  clothing,  and,  over  all,  a  gauze  bandage  is  ap- 
plied with  very  light  pressure.  The  dressing  should  be  changed  and 
fresh  ointment  applied  every  six  hours.  Wet  dressings  in  the  manage- 
ment of  this  condition  in  infants  are  not  advised.  In  five  cases  the 
mastitis  was  beyond  control  when  first  seen,  and  suppuration  of  the 
gland — mammary  abscess — followed,  requiring  incision  and  drainage, 
with  loss  of  the  gland  substance. 

Mammary  Abscess  in  Infants. — Mammary  abscess  is  the  result  of  a 
mastitis  which  has  failed  to  undergo  resolution.  It  occurs  as  fre- 
quently in  males  as  in  females.  All  my  cases  but  two  were  seen  in  in- 
stitutions or  in  out-patient  work.  In  five  the  abscess  developed  under 
my  own  observation.  In  a  female  child,  a  patient  at  the  New  York 
Infant  Asylum,  both  glands  were  entirely  destroyed.  As  soon  as  pus  is 
discovered  the  abscess  should  be  incised  and  drained,  with  a  view  to 
saving  as  much  of  the  gland  as  possible.  Of  course,  this  advice  applies 
particularly  to  a  female  patient.  Wet  dressings  are  not  applicable 
-  in  cases  of  young  infants  when  the  parts  covering  the  thorax  or  abdo- 
men are  involved.     It  is  my  custom  to  protect  the  skin  from  infection 


156  THE    PRACTICE    OF    PEDIATRICS 

by  the  use  of  a  25  per  cent,  boric-acid  ointment  in  cold  cream  as  a  base. 
This  is  apphed  on  old  linen  about  the  abscess  opening.  The  dressing 
should  be  changed  three  times  daily. 

TETANUS  NEONATORUM 

Tetanus  is  an  acute  infectious  disease  caused  by  the  tetanus  bacil- 
lus, an  organism  having  its  natural  habitat  in  garden-soil  or  dung- 
heaps.  Its  point  of  entrance  into  the  human  body  may  be  a  lacerated 
wound,  a  mere  abrasion,  or,  as  is  the  case  in  tetanus  neonatorum,  the 
umbilicus.  The  local  reaction  may  be  very  slight  or  attended  by 
suppuration. 

Tetanus  is  extremely  rare  in  our  hospitals  and  institutions  for 
children  because  of  the  care  exercised  in  treating  the  umbilical  wound. 
Wherever  gross  uncleanliness  prevails,  tetanus  neonatorum  will  be 
found.  It  is  particularly  prevalent  among  savage  and  half-civilized 
races. 

The  Tetanus  Bacillus. — The  tetanus  bacillus  is  a  slender,  slightly 
mobile  organism,  positive  to  Gram's  stain,  growing  only  anaerobically, 
and  developing  a  round  spore  characteristically  placed  at  one  end  of 
the  rod,  giving  it  a  nail  or  drumstick  form.  It  was  described  by 
Nicolaier  in  1885,  and  cultivated  four  years  later  by  Kitasato. 

The  bacilli  remain  localized  at  the  seat  of  infection,  whence  their 
toxins  are  carried  along  the  axis-cylinders  of  the  motor  nerves  to  the 
motor  cells  of  the  spinal  cord,  pons  varolii,  medulla  oblongata,  and,  to 
a  lesser  degree,  the  brain  cortex.  The  localized  spasms  characteristic 
of  the  disease  are  due  to  the  action  of  the  tetanus  toxin  on  the  ganglion- 
cells. 

Incubation. — From  the  second  to  the  ninth  day  is  the  usual  period 
for  the  development  of  the  disease,  although  it  may  appear  as  late  as 
the  fifth  or  sixth  week.  The  period  of  incubation  of  the  tetanus  bacillus 
in  man  is  possible  of  wide  variation.  The  disease  may  appear  immedi- 
ately after  birth,  or  be  delayed  for  five  or  six  weeks.  Few  cases,  how- 
ever, develop  after  the  third  week  of  life. 

Pathology. — The  lesions  found  at  autopsy  in  infants  dead  of  tetanus 
neonatorum  are  few  and  non-specific  in  character.  Acute  omphalitis 
is  usually  present.  The  thoracic  and  abdominal  viscera  do  not  show 
any  abnormality.  The  meninges  of  the  brain  and  spinal  cord  are  con- 
gested, while  small  hemorrhages  into  the  nerve-substance  are  frequent. 
These  are  manifestly  the  result,  and  not  the  cause,  of  the  tetanic 
spasms. 

On  microscopic  examination  degenerative  changes  in  the  nerve- 
cells  of  the  gray  matter  of  the  spinal  cord  are  noted,  but  these  changes 
are  in  no  way  specific. 

Prognosis. — Few  cases  recover.  Holt  reports  one  recovery.  The 
mortality  is  high.  Those  writers  who  have  seen  much  of  the  disease 
place  the  mortality  at  95  to  98  per  cent. 

Symptoms. — The  earliest  symptom  usually  observed  is  difficulty 
in  nursing.     The  child  attempts  to  grasp  the  nipple  and  lets  go  sud- 


HEMORRHAGIC   DISEASES   OF   THE    NEWLY  BORN  157 

denly  and  cries.  Perhaps  the  child  will  give  a  sudden  start  and  cry  as 
though  in  acute  pain,  which  is  doubtless  the  case.  Examination  of 
the  patient  will  show  well-marked  trismus;  the  jaw  is  set;  the  jaw  mus- 
cles are  tense.  Stiffening  and  relaxation  of  the  muscles  occur.  As 
the  case  progresses  the  muscles  of  deglutition  become  involved,  and 
swallowing  is  impossible.  The  lips  are  said  to  pucker  in  the  position 
of  whistling. 

The  temporary  relaxations  become  shorter;  there  is  a  tonic  spasm, 
and,  at  the  slightest  irritation,  such  as  the  dropping  of  a  pencil  or  a 
sudden,  awkward  movement  of  an  attendant,  the  muscle  spasm  in- 
creases until  a  marked  permanent  opisthotonos  results.  The  tem- 
perature is  usually  high — 104°F.  to  106°F. ;  the  pulse  very  rapid — 180 
to  200.  Death  is  usually  due  to  exhaustion.  Spasm  of  the  respira- 
tory muscles  is  probably  a  factor. 

Treatment. — The  treatment  consists  in  the  use  of  antispasmodics — 
among  which  bromid  and  chloral  are  most  frequently  used.  Large 
doses  are  necessary. 

In  Holt's  recovery  case  8  grains  of  sodium  bromid  were  given 
every  two  hours. 

The  patient  is  to  be  kept  very  quiet.  Food  and  drugs  are  adminis- 
tered through  a  tube. 

Tetanus  Antitoxin. — Tetanus  antitoxic  serum  is  made  by  inoculat- 
ing a  horse  with  tetanus  toxin  formed  by  the  growth  in  bouillon  of  the 
tetanus  bacillus.  Its  prophylactic  use  has  been  of  far  greater  value 
than  its  curative  effect,  and  in  every  case  of  possible  tetanus  infection  a 
dose  of  1500  units  of  the  antitoxin  should  be  injected  subcutaneously 
near  the  wound.  In  order  to  do  good,  after  symptoms  of  tetanus  have 
appeared,  the  antitoxin  must  be  administered  as  early  as  possible.  The 
New  York  City  Board  of  Health  advises  giving  the  initial  dose  of 
10,000  units  intravenously,  and,  if  possible,  also  into  the  spinal  canal 
and  into  the  sheath  of  the  nerve  of  the  affected  part.  These  energetic 
measures  should  be  followed  by  subcutaneous  doses  of  5000  to  10,000 
units  every  six  to  twelve  hours  for  four  days.  In  more  severe  cases, 
or  in  those  in  which  symptoms  have  been  present  for  several  days 
before  the  treatment  was  begun,  the  initial  dose  should  be  doubled. 
It  is  also  recommended  that  the  wound  be  treated  with  a  solution  of 
iodin  and  that  large  amounts  of  water  be  given  for  its  diuretic  effect, 
since  tetanus  toxin  is  eliminated  by  the  kidneys. 

HEMORRHAGIC  DISEASES  OF  THE  NEWLY  BORN 

In  1861  von  Hecker  and  Buhl  described  a  series  of  cases,  under  the 
title  of  "Acute  Fett-Degeneration  der  Neugeborenen,"  that  presented 
a  somewhat  similar  picture  without  evidence  of  either  syphilis  or  navel 
sepsis.  Since  that  time  this  condition  has  been  commonly  called 
Buhl's  disease.  In  the  original  article  it  was  noted  that  most  of  the 
children  were  born  in  asphyxia.  These  cases  showed  the  typical 
symptoms  of  the  disease,  and  at  autopsy,  all  the  viscera  showed  mul- 
tiple hemorrhages  as  large  as  pin-heads  or  larger,  together  with  fatty 


158  THE    PRACTICE    OF    PEDIATRICS 

changes  that  may  be  extensive.  The  authors  do  not  attempt  to  explain 
the  etiology,  but  think  that  the  condition  is  not  due  to  navel  infection 
and  that  it  is  not  a  manifestation  of  hemophilia  because  the  ratio  of 
males  to  females  is  not  maintained  as  in  hemophilia.  In  conclusion 
they  say:  "  It  is  hardly  necessary  to  state  that  one  here  has  to  do  with 
a  disturbance  of  metabolism  manifested  over  the  whole  body,  in  which 
the  changes  in  single  organs  are  only  a  partial  expression  of  the  whole 
disease.  This  disturbance  is  evidently  inborn,  acquired  in  the  last 
days  before  birth." 

In  1879  Winckel  tried  to  establish  an  entity  distinct  from  the  so- 
caUed  Buhl's  disease  by  describing  a  series  of  cases  that  manifested  a 
slightly  different  clinical  and  pathologic  picture.  He  considered  this 
condition  distinct  from  Buhl's  disease,  chiefly  because  it  seemed  to  be 
epidemic  in  character  and  because  the  hemorrhages  were  more,  and 
the  fatty  changes  less,  prominent  than  in  the  disorder  described  by 
Buhl.  Winckel  recognized  the  similarity  of  this  condition  to  that  of 
intoxication  by  phosphorus,  arsenic,  and  potassium  chlorate,  and  he 
ruled  out,  by  careful  histories  and  by  chemical  examination*  of  the 
viscera,  any  possible  participation  of  these  drugs  in  the  etiology  of  his- 
cases. 

In  more  recent  times  the  Germans,  in  particular,  have  come  to  re- 
gard as  Buhl's  disease  any  condition  affecting  the  new-born,  that  pro- 
duces a  severe  icterus  and  fatty  infiltration  without  evidence  of  infec- 
tion; whereas  any  similar  condition,  of  which  the  chief  features  are 
icterus  and  hemoglobinuria,  has  been  looked  upon  as  WinckeVs  disease. 

These  two  classifications,  however,  have  failed  to  sufiice  for  all  the 
hemorrhagic  icteric  conditions  of  the  new-born  infant. 

Various  other  names  have  sprung  into  rather  general  use,  and  have 
served  to  complicate  the  nomenclature  by  adding  terms  based  solely 
on  clinical  and  morbid  anatomic  differences. 

Meloena  neonatorum  is  a  term  that  has  been  applied  to  conditions 
in  which  hemorrhage  has  occurred  from  the  gastro-intestinal  tract, 
without  necessarily  any  clinical  evidence  of  hemorrhage  elsewhere. 
Since  1829,  when  Cruveilhier  found  ulcers  in  the  stomach  of  an  infant 
who  presented  evidence  of  a  true  melena,  many  others  have  recorded 
their  presence  with  the  result  that  a  gastric  or  intestinal  ulcer  is  usually 
considered  to  be  the  source  of  the  hemorrhage  in  these  conditions. 

Syphilis. — These  hemorrhagic  conditions  have  frequently  been 
found  associated  with  congenital  syphilis.  There  are  hemorrhages, 
cyanosis,  edema,  icterus,  etc.,  but  in  many  cases  evidence  of  syphilis 
is  wanting.  Cases  of  Buhl's  disease  have  been  recorded  by  Fursten- 
burg  as  occurring  spontaneously  even  in  the  offspring  of  domestic 
animals,  where  presumably  the  presence  of  syphilis  may  be  safely 
excluded. 

Bacteria. — The  role  of  bacteria  has  received  the  greatest  considera- 
tion, for  the  following  reasons: 

1.  The  close  similarity  between  these  conditions  and  the  picture 
produced  by  navel  sepsis. 


HEMORRHAGIC   DISEASES   OF  THE   NEWLY  BORN  159 

2.  The  epidemicity  of  at  least  one  group  (Winckel's). 
•  3.  The  finding  of  organisms  at  autopsy. 

4.  The  experimental  production  in  animals  of  certain  of  these 
conditions  by  inoculation  with  bacteria. 

The  belief  is  now  almost  universally  held  that  many  different 
bacteria  may  produce  these  diseases,  because  of  the  variety  of  micro- 
organisms that  has  been  found  at  autopsy  (staphylococci,  streptococci, 
Gartner's  bacillus,  pyocyaneus,  colon,  and  various  other  types). 
The  inoculation  of  animals  by  many  of  these  organisms  has  frequently 
been  followed  by  the  production  of  diseases  similar  to  those  in  human 
beings.  In  certain  cases,  at  autopsy,  lesions  indicative  of  an  infectious 
process,  as,  for  example,  hyperplasia  of  intestinal  lymphatic  tissue, 
have  been  found,  but,  on  the  other  hand,  such  findings  are  frequently 
absent,  and  it  is  very  striking  that  in  many  cases  there  seems  to  be 
very  insufficient  evidence  that  infection  has  played  an  important  role. 

In  general  one  may  conclude  that  there  is  strong  evidence  favoring 
the  idea  that  many  cases  were  caused  by  infections,  and,  on  the 
contrary,  insufficient  evidence  for  assuming  that  all  are  infections. 

Mechanical  Means. — Mechanical  factors,  such  as  trauma,  thrombo- 
sis, embolism  (Landau),  deserve  only  mention,  as  they  have  been  found 
only  very  occasionally  (Thomson). 

Heredity. — The  possible  importance  of  hereditary  influences  was 
considered  by  von  Hecker  and  Buhl  when  they  stated  that  their 
disease  was  evidently  inborn,  and  acquired  during  the  last  few  days 
of  pregnancy.  The  relation  of  heredity  to  true  hemophilia  neonatorum 
needs  no  further  mention. 

There  are  certain  affections  of  the  adult,  at  present  of  unknown 
etiology,  which,  if  transmitted  to  the  fetus,  might  cause  their  various 
syndromes  in  the  new-born.  Reference  is  made  particularly  to  the 
closely  related  conditions  of  acute  yellow  atrophy,  of  eclampsia,  and 
of  certain  septicemic  conditions.  Numerous  observations  are  on 
record  describing  the  pathologic  changes  in  the  offspring  of  eclamptic 
mothers,  and  it  is  particularly  interesting  that  in  general  the  ab- 
normal features  correspond  closely  with  the  icteric  and  hemorrhagic 
syndromes  of  the  new-born. 

Each  report  summarizes  the  pathologic  changes  as  thrombosis  and 
parenchymatous  degeneration,  fatty  degeneration  or  necrosis,  espe- 
cially in  the  liver  and  kidneys,  hemorrhages  in  the  organs,  and  sub- 
phrenal,  subpericardial,  and  subendocardial  extravasations  of  blood. 

Chemical  Agents. — Finally,  intoxication  by  known  chemical  agents 
occasions  symptoms  and  pathologic  changes  similar  to  the  disease  in 
question.  Among  this  long  list  of  agents  may  be  mentioned  phos- 
phorus, arsenic,  potassium  chlorate,  and  chloroform.  That  there  are 
many  features  of  these  conditions  that  suggest  a  common  general 
process  has  already  been  emphasized  by  Knopfelmacher. 

Metabolic  Changes. — The  symptoms  and  gross  changes  are  sug- 
gestive of  poisoning  by  the  above-mentioned  agents,  but  they  also 
occur  in  conditions  of  obscure  etiology,  such  as  acute  yellow  atrophy, 


160  THE    PRACTICE    OF    PEDIATRICS 

eclampsia,  and  cyclic  vomiting  of  children.  All  the  chief  features 
that  characterize  this  latter  group,  including  certain  metabolic  phe- 
nomena, such  as  appearance  of  lactic  acid  and  sugar  in  the  urine,  not 
to  mention  others,  are  known  to  occur  also  after  respiration  of  rarefied 
air  or  after  asphyxia  from  any  cause,  that  is  to  say,  from  lack  of 
oxygen.  In  phosphorus-poisoning  there  is  a  deficiency  of  available 
oxj'gen.  Chloroform  does  not  belong  to  this  group,  producing  de- 
ficient oxidation  of  the  tissues ;  but  it  would  seem,  d  'priori,  that  there 
was  some  evidence  to  suggest  the  existence  of  a  causal  relationship 
between  chloroform  used  at  labor  and  the  occurrence  of  some  of 
these  various  conditions  of  the  new-born. 

Evarts  Graham  (Chicago)  concludes,  after  a  careful  experimental 
study,  and  review  of  the  literature  of  which  the  proceeding  paragraphs 
are  a  resume,  that  the  conditions  of  the  new-born  characterized  by  a 
hemorrhagic  tendency,  icterus,  and  fatty  changes,  are  probably  all 
syndromes  which  may  occur  as  the  result  of  a  number  of  toxic  agents. 
He  has  produced  experimentally  the  essential  features  of  the  diseased 
group  by  the  administration  of  chloroform  to  the  point  of  asphyxia. 

Duke  believes  that  the  bleeding  is  due  to  a  deficiency  in  the 
number  of  platelets  in  the  blood,  and  thus  absence  of  thrombus  for- 
mation, which  is  essential  in  order  to  produce  clotting.  In  some 
cases  the  coagulation  time  is  normal,  in  others,  abnormal. 

A  considerable  number  of  these  cases  have  come  under  my  personal 
observation.  I  have  repeatedly  seen  hemorrhages  from  the  newly 
born  occur  in  the  internal  organs  and  from  various  portions  of  the 
body.  A  colored  infant  at  the  New  York  Nursery  and  Child's 
Hospital  bled  to  death  in  the  pericranial  tissues  without  a  sign  of 
hemorrhage  elsewhere.  Some  cases  were  due  to  proved  sepsis;  in 
others  there  was  no  demonstrable  lesion  of  the  blood  or  vascular 
apparatus.  It  is  this  latter  type  that  offers  the  most  promising 
results  from  the  human  serum  treatment  referred  to  below. 

Treatment. — The  use  of  styptics  and  astringents  for  controlling 
the  hemorrhage  is  useless.  The  only  measure  that  has  assisted  me 
in  any  way  has  been  the  application  of  pressure  to  the  bleeding  parts, 
and  this  is  not  possible  in  many  situations.  Adrenalin,  locally  or  by 
internal  administration,  has  not  been  of  any  appreciable  service. 

Ilhistrative  Case. — One  of  the  most  important  contributions  to  the  literature  of 
hemorrhage  in  the  new-born  was  presented  in  the  Medical  Record  of  May  30,  1909, 
by  Dr.  Samuel  W.  Lambert,  of  New  York  City.  In  this  case  a  direct  transfusion 
of  blood  from  the  father  to  the  child  was  successful  in  stopping  the  hemorrhage 
when  the  case  was  almost  hopeless. 

Within  the  past  few  years  the  method  introduced  by  Dr.  J.  E. 
Welch,  of  New  York,  has  been  successfully  followed  by  many  phy- 
sicians. It  has  been  successful  in  five  cases  coming  under  my 
observation. 

Welch's  methods  consist  in  the  injections,  under  the  skin  of  the 
infant,  of  human  serum  which  has  been  obtained  under  antiseptic 
precautions.     The    results    are    usually    prompt.     The    hemorrhage 


HEMORRHAGIC   DISEASES   OF   THE    NEWLY  BORN  161 

often  ceases  after  the  first  or  second  injection.     The  injections  should 
be  continued  until  the  hemorrhages  cease. 

Welch  writes  as  follows:* 

"As  to  the  dose  of  serum  to  be  used  in  any  given  case,  it  should  be 
said  that  this  depends  upon  the  urgency  of  the  case.  One  is  apt  to  err 
on  the  side  of  too  small  doses.  It  is  advisable  to  begin  with  at  least 
1  ounce  and  repeat  three  times  per  day  if  the  infant  is  bleeding  only 
moderately.  In  severe  cases  it  should  be  given  every  two  hours,  and 
in  larger  quantities  if  necessary.  It  is  very  important  to  begin  the 
treatment  at  the  first  indication  of  bleeding,  however  apparently  in- 
significant. Slight  bleeding  of  the  cord  may  be  accompanied  by  fatal 
internal  hemorrhage  if  not  stopped  immediately. 

"  The  blood  is  very  easily  collected.  The  apparatus  I  have  devised 
consists  of  a  rubber  cork  through  which  are  two  perforations.  Through 
one  perforation  is  fitted  a  U-shaped  glass  tube,  to  the  outer  end  of  which 
is  attached,  by  means  of  a  piece  of  rubber  tubing,  a  short  aspirating 
needle  having  a  No.  19  caliber.  The  needle  is  cotton-plugged  into  a 
small  test-tube,  in  which  it  is  sterilized.  Through  the  other  perfora- 
tion is  inserted  a  fusiform  glass  tube  containing  cotton  to  prevent  con- 
taminating the  contents  of  the  flask.  A  small  suction  tube  is  placed 
on  this  latter  for  drawing  the  blood  into  the  flask.  The  needle  is  in- 
serted into  a  vein  at  the  elbow  and  the  desired  amount  of  blood  with- 
drawn. The  blood  is  allowed  to  coagulate  in  a  slanting  position  in  the 
fliask,  and  the  serum  is  withdrawn  as  rapidly  as  it  separates;  it  is  then 
ready  for  use.  It  is  advisable  to  continue  the  use  of  the  serum  for  a 
day  or  two  after  the  bleeding  has  ceased,  in  order  to  insure  a  control  of 
hemorrhage  that  may  be  going  on  in  hidden  sources." 

During  the  past  year  I  have  successfully  treated  three  cases  of 
hemorrhage  in  the  newly  born  by  the  use  of  human  blood  injections. 
The  blood  is  readily  drawn  from  the  basilic  vein  of  the  donor  and 
injected  into  the  buttocks  of  the  patient.  This  is  the  most  rapid 
method  of  treatment  as  no  tests  are  required  for  hemolysis  and  ag- 
glutination. One  ounce  of  blood  was  used  in  each  case,  completely 
controlling  the  hemorrhage. 

*  American  Journal  Medical  Sciences,  June,  1910. 
11 


IV.  DISEASES  OF  THE  MOUTH  AND  ESOPHAGUS 
SPRUE  (THRUSH;  MYCOTIC  STOMATITIS) 

The  disease  makes  its  appearance  in  the  form  of  small  white  masses 
of  about  the  size  of  a  pin-head.  The  tongue  and  the  inner  sides  of  the 
cheeks  are  favorite  sites  for  the  growth,  although  in  severe  cases  the 
entire  buccal  cavity  may  be  studded,  as  though  finely  curdled  milk  had 
been  scattered  over  the  surface,  and  it  may  extend  into  the  stomach. 
The  growth  is  firmly  adherent,  and  its  forcible  removal  produces  slight 
bleeding.  Sprue  is  invariably  associated  with  uncleanliness,  and  occurs, 
as  a  rule,  in  weakly  and  marasmic  nurslings  and  in  the  bottle-fed — 
more  frequently  in  the  latter.  The  disease  is  rarely  seen  after  the  sixth 
month. 

Sym.ptoins. — Thrush,  soor,  or  mycotic  stomatitis  is  due  to  Oidium 
albicans,  an  organism  which  stands  between  the  yeasts  and  the  fungi. 
The  threads  of  the  mycelium  end  in  egg-shaped  conidia  which  bud 
and  form  new  hyphse.  Spores  are  formed  only  under  favorable 
cultural  conditions.  Preparations  made  from  the  white  patches  on  the 
buccal  mucosa  show  both  mycelia  and  yeast-like  conidia. 

An  infant  with  this  disease  gives  evidence  of  much  pain  and  discom- 
fort while  nursing  or  while  feeding  from  the  bottle.  Active  gastro- 
enteric disturbances,  such  as  vomiting  and  diarrhea,  may  be  associated 
with  sprue,  but  such  association  is  not  the  rule.  Time  and  again  I  have 
seen  cases  in  which  there  were  absolutely  no  other  signs  of  the  disease 
than  the  characteristic  mouth  lesions  and  the  patient's  refusal  of  food. 
The  average  case  may  easily  be  cured  in  a  week  if  treatment  is  carefully 
carried  out.  Sprue  is  not  contagious,  and  if  the  means  of  prophylaxis, 
which  will  be  suggested,  are  used  as  a  part  of  the  daily  routine,  the  dis- 
ease will  never  appear. 

Treatment. — If  the  patient  is  breast-fed,  the  mother's  nipples  must 
be  washed  with  a  saturated  solution  of  boric  acid  and  moistened  with 
alcohol,  diluted  one-half,  which  is  allowed  to  evaporate  before  each 
nursing.  If  the  infant  is  bottle-fed,  both  nipple  and  bottle  should  be 
boiled  after  each  nursing,  and  the  nipples  turned  inside  out  and  scrubbed 
with  borax  water — one  ounce  of  borax  to  a  pint  of  water.  In  either 
case  the  mouth  should  be  washed  with  a  saturated  solution  of  boric 
acid  after  each  feeding.  For  this  purpose  a  generous  amount  of  ab- 
sorbent cotton  loosely  wrapped  around  the  clean  index-finger  of  the 
mother  or  nurse  is  placed  in  the  cold  solution,  and  then,  without  expres- 
sion of  the  water,  introduced  by  the  finger  into  the  child's  mouth.  In 
care  of  sprue,  the  application  should  be  brought  gently  into  contact 
with  the  diseased  parts,  first  on  one  side  and  then  on  the  other,  and 
finally  pressed  over  the  tongue  and  under  the  tongue.  It  is  well  to 
have  the  child  rest  on  the  side  or  abdomen  so  that  the  fluid  which  is 

162 


STOMATITIS  163 

pressed  out  by  the  manipulation  of  the  cotton  against  the  cheek  and 
jaws  can  readily  escape  from  the  mouth.  The  washing,  which  really 
amounts  to  an  irrigation,  can  be  done  in  a  few  seconds,  without  the 
slightest  danger  of  abrading  the  epithelium.  In  obstinate  cases  this 
treatment  may  be  supplemented  by  penciling  once  a  day  with  1  per 
cent,  solution  of  formalin. 

Internal  medication  is  of  no  value  except  as  a  means  of  correcting 
any  intestinal  derangement  that  may  exist,  with  a  view  to  improving 
the  general  condition.  If  the  bottle  or  breast  is  refused,  spoon-feeding, 
for  a  few  days,  may  be  found  necessary,  and  in  any  event  will  hasten 
the  cure.  If  the  child  is  nursed,  the  mother's  milk  may  be  drawn  with 
a  breast-pump  (see  p.  35)  or  pressed  out  with  the  fingers  and  then  fed 
by  the  spoon.  The  domestic  remedy,  honey  and  borax,  should  not 
be  used  in  treating  any  of  the  inflammatory  diseases  of  the  mouth  in 
children. 

STOMATITIS 

The  term  stomatitis  is  applied  to  an  inflammation  of  the  mucous 
membrane  of  the  mouth.  Three  types  are  usually  described  by 
pediatric  authors — the  catarrhal,  the  aphthous,  and  the  ulcerative. 
This  division  is  perhaps  more  the  result  of  the  habit  of  copying  from 
former  writers,  than  of  clinical  observation.  Among  several  thousand 
out-patient,  institution,  and  hospital  patients,  it  has  been  my  privilege 
to  treat  many  cases  of  stomatitis. 

There  are  many  cases  of  catarrhal  stomatitis  which,  under  treat- 
ment, go  no  further;  other  cases,  with  or  without  treatment,  go  on  to 
the  development  of  aphthae,  or  an  ulcerative  condition.  Both  con- 
ditions may  be  combined.  Many  cases,  when  they  appear  for  treat- 
ment, have  the  so-called  aphthous  spots  already  developed,  but  the 
condition  described  as  "catarrhal  stomatitis"  also  is  present.  Other 
cases  when  they  come  to  us  show  marked  ulceration,  but  never  without 
catarrhal  symptoms. 

Bacteriology.— Catarrhal,  aphthous,  and  ulcerative  stomatitis  have 
no  specific  bacteriologic  etiology. 

Etiology.— The  cause  of  the  disease  is  unquestionably  an  infection, 
and  there  is  no  doubt  that  it  is  contagious.  As  to  the  nature  of  the 
infection,  positively  nothing  is  known.  The  combined  action  of 
several  varieties  of  microorganisms  is  the  most  plausible  explanation. 
I  have  known  stomatitis  to  go  through  an  entire  family  of  several 
children.  Authors  are  prone  to  attribute  the  trouble  primarily  to 
mechanical  irritation,  such  as  careless  manipulation  during  the  mouth 
toilet;  but  the  majority  of  my  cases  when  they  applied  for  treatment 
had  never  been  accustomed  to  mouth  toilets  of  any  kind.  The 
giving  of  overheated  food  is  supposed  by  some  to  be  a  causative 
agent.  If  this  were  the  case,  75  per  cent,  of  the  infants  among  the 
poorer  classes  would  never  be  free  from  the  disease.  The  food  of  bottle- 
fed  children  unless  carefully  watched  is  almost  invariably  given  too 
hot.     The  disease,  however,  is  not  limited  to  dispensary  patients.     I 


164  THE    PRACTICE    OF    PEDIATRICS 

have  seen  many  cases  among  the  well-to-do.  Where  gross  uncleanliness 
is  the  family  habit,  the  number  of  cases  of  stomatitis  will,  for  obvious 
reasons,  be  greater;  there  are  more  bacteria  to  carry  infection.  Chil- 
dren whose  mouths  are  carefully  cleaned  after  each  feeding  do  not 
develop  stomatitis.  To  teach  that  a  child's  mouth  should  not  be 
washed  because  an  indifferent  doctor  may  fail  to  instruct  the  mother 
or  nurse  as  to  how  it  should  be  done  is  rank  heresy.  When  errors  of 
the  mother  or  nurse  occur  in  performing  the  various  offices  for  the 
child,  it  is  my  observation  that,  nine  times  out  of  ten,  the  fault  is 
due  to  lack  of  instruction  by  the  physician.  The  mouth  may  be  very 
effectually  cleansed  without  injuring  the  mucous  membrane  in  the 
slightest  degree. 

Symptoms. — The  first  symptom  of  a  stomatitis  is  a  superficial  ca- 
tarrhal inflammation  of  the  mucous  membrane  of  the  mouth.  There 
is  a  redness  and  injection  of  the  gums.  If  "aphthae"  develop,  small 
grayish  plaques  appear  on  the  mucous  surface  of  any  portion  of  the 
buccal  cavity.  In  mild  cases  there  may  be  but  there  or  four  areas. 
In  a  case  of  moderate  severity  the  mucous  membrane  of  the  gums,  the 
hard  and  soft  palate,  and  the  inner  side  of  the  cheeks  will  be  studded 
with  ulcerated,  grayish-white  areas,  varying  in  size  from  a  pin-head 
to  a  split-pea.  Occasionally  the  areas  coalesce,  forming  larger  plaques 
of  a  serpiginous  type. 

Ulceration,  which  ordinarily  does  not  appear  until  after  the  catarrhal 
condition  has  been  present  for  at  least  three  or  four  days,  will  first  be 
noticed  as  a  faint  yellow  line  at  the  margin  of  the  gum  where  it  joins 
the  teeth.  This  is  the  commencement  of  what  Virchow  describes  as 
"necrobiosis."  Ulceration  never  occurs  unless  teeth  are  present.  I 
have  never  known  a  case  to  go  on  to  ulceration  in  a  baby  fed  entirely 
at  the  breast.  Whether  the  case  remains  simply  catarrhal,  or  whether 
aphthae  or  ulceration  or  both  result,  certain  symptoms  are  common  to 
all.  There  is  a  marked  increase  in  the  flow  of  saliva,  which,  in  some 
cases,  may  be  said  to  stream  from  the  mouth,  running  down  over  the 
chin  and  soiling  the  clothes.  On  account  of  its  acid  properties  it  causes 
an  irritation  of  the  skin  and  even  an  eczema.  The  mouth  is  hot  and 
painful.  Fever  is  present  in  a  slight  degree,  both  when  the  condition 
is  simply  catarrhal  and  when  aphthae  are  present.  There  is  but  little 
prostration  and  the  child  appears  but  slightly  indisposed.  In  cases 
which  go  on  to  ulceration,  the  fever  may  be  very  high.  I  have  fre- 
quently seen  it  104°F.  or  over.  In  one  case  it  reached  107°F.  No 
cause  except  the  ulcerative  stomatitis  could  be  found  for  the  fever. 
Under  properly  directed  treatment  this  child  recovered  in  a  few  days. 

On  account  of  the  pain  occasioned  by  drawing  on  the  nipple,  nutri- 
tion may  be  considerably  interfered  with.  The  child  takes  the  breast 
or  bottle  greedily,  draws  a  few  times,  stops,  and  begins  to  cry.  If  he  is 
urged  to  try  again,  the  behavior  is  repeated.  The  pain  appears  to  be 
particularly  severe  when  aphthae  are  present.  The  advent  of  ulcera- 
tion will  be  indicated  by  a  change  in  the  breath,  which  becomes  dis- 
gustingly foul.     The  gums  are  thick,  spongy,  and  bleed  easily,  and  in 


STOMATITIS  165 

some  cases  overlap  the  teeth  very  early  in  the  ulcerative  stage.  If  a 
case  has  been  neglected  or  improperly  treated,  which  was  the  history  of 
not  a  few  of  my  dispensary  patients,  the  ulceration  is  often  so  ex- 
tensive that  the  teeth  become  loose  as  a  result  of  the  destruction  of  the 
gums,  and  their  removal  is  necessary.  Strong,  vigorous  children  are 
as  susceptible  to  the  disease  as  are  the  rachitic,  the  badly  fed,  or  the 
generally  delicate. 

Prognosis. — The  prognosis  is  good.  All  cases  recover  if  seen  early 
and  if  properly  treated.  Loss  of  teeth  may  result  in  those  seen  when 
the  process  is  well  advanced. 

Treatment. — Mouth-washing. — When  the  stomatitis  is  catarrhal  or 
aphthous,  preventive  treatment — the  washing  of  the  mouth  after  each 
feeding  with  a  saturated  solution  of  boric  acid  in  boiled  water — is 
also  curative.  A  baby's  mouth  should  be  washed  as  follows:  The 
child  is  placed  on  its  side  or  on  its  stomach,  the  index-finger  of  the 
mother  or  nurse  being  thoroughly  wrapped  in  absorbent  cotton.  The 
finger  is  then  dipped  into  the  solution,  and  without  expressing  the  fluid 
it  is  placed  in  the  child's  mouth.  By  gentle  pressure  upon  the  gums 
and  cheeks  a  sufficient  amount  of  the  fluid  will  be  expressed  to  run  out 
of  the  mouth  and  effectively  cleanse  it.  The  washing  is  assisted  by 
the  opposition  offered  by  the  child  to  the  manipulation  of  the  tongue, 
cheeks,  and  jaws. 

Drugs. — Internal  medication  is  of  no  value  except  indirectly.  If 
there  is  a  disordered  digestive  tract,  it  should  receive  attention  by  diet 
and  saline  laxatives.  Calomel  should  not  be  given.  Whether  the  con- 
dition was  catarrhal  or  aphthous,  I  have  never  found  it  necessary  to  use 
other  means  than  the  free  mouth-washing.  Astringents  and  caustics 
have  never  been  necessary.  The  cases  usually  recover  in  from  four  to 
seven  days,  under  strict  attention  to  cleanliness  as  regards  the  feeding 
apparatus  or  the  mother's  nipple,  together  with  the  free  use  of  the 
boric-acid  solution  as  a  mouth-wash. 

Feeding. — The  food  problem  is  oftentimes  a  difficult  one  to  deal 
with,  particularly  in  the  case  of  nurslings,  on  account  of  the  pain  caused 
by  drawing  on  the  nipple,  the  child  refusing  absolutely  to  nurse.  In 
some  cases  it  may  be  necessary  to  draw  the  milk  with  a  breast-pump, 
and  for  a  day  or  two  feed  the  baby  with  a  spoon.  With  the  bottle-fed, 
spoon-feeding  may  also  be  resorted  to.  The  child  will  take  the  nour- 
ishment much  better  if  it  is  given  cool.  Small  pieces  of  ice  and  tea- 
spoonful  doses  of  cold  water  are  taken  eagerly. 

Treatment  after  Ulceration. — With  the  development  of  ulceration 
a  change  in  the  management  is  necessary,  both  as  regards  a  mouth-wash 
and  the  necessity  for  internal  medication.  Among  the  local  measures 
hydrogen  peroxid  as  a  mouth-wash,  one  part  of  a  3  per  cent,  solution 
in  two  parts  of  water,  used  after  each  feeding,  has  given  the  best  results. 
Such  means,  however,  are  rarely  necessary  if  the  case  is  seen  early. 
I  never  employ  other  than  the  usual  means  of  cleanliness — the  boric- 
acid  solution — except  in  cases  that  show  a  considerable  destruction 
of  tissue. 


166  THE    PRACTICE    OF    PEDIATRICS 

Chlorate  of  Potash. — In  the  internal  administration  of  chlorate  of 
potash  we  have  what  is  practically  a  specific  in  this  disease.  Its  ad- 
ministration should  be  commenced  as  soon  as  the  condition  is  recog- 
nized. I  usually  prescribe  it  in  the  syrup  of  raspberry,  using  one  part 
of  the  sjTup  to  two  parts  of  water.  For  a  child  under  eighteen  months 
of  age  I  order  two  grains  at  intervals  of  two  or  three  hours — not  more 
than  ten  grains  in  twenty-four  hours ;  for  a  child  from  eighteen  months 
to  three  years  of  age,  two  or  three  grains  at  the  same  intervals,  not 
more  than  fifteen  grains  in  twenty-four  hours.  With  the  above 
dosage  it  will  be  necessary,  in  the  average  case,  to  continue  the  drug 
from  three  to  five  days.  Very  often,  after  the  improvement  is  well 
marked,  I  reduce  the  dose  one-half  and  continue  it  for  three  or  four 
days  longer. 

Dangers  of  Chlorate  of  Potash. — Much  has  been  written  concerning 
the  danger  of  the  internal  use  of  chlorate  of  potash  in  children,  particu- 
larly in  relation  to  its  effects  upon  the  kidneys.  If  the  use  of  the  drug 
in  suitable  doses  were  of  special  danger  in  this  respect,  the  free  use  of 
the  chlorate  of  potash  and  iron  mixture,  so  extensively  prescribed  in 
diphtheria  in  the  pre-antitoxin  period,  would  have  been  universally 
condemned.  I  have  never  seen  any  unpleasant  effects  from  chlorate 
of  potash  given  in  doses  of  10  to  20  grains  daily,  and  I  have  used  it  in 
many  hundreds  of  cases  of  acute  inflammatory  conditions  of  the  throat 
and  mouth. 

CANCRUM  ORIS  (NOMA) 

No  single  microorganism  has  been  proved  to  be  the  cause  of  noma. 
Spirilla  and  fusiform  bacilli  have  been  found  (Weaver  and  Tunnicliff), 
not  only  in  the  necrotic  tissue,  but  in  the  surrounding  healthy  parts. 
Whether  these  organisms  represent  the  primary  cause  of  the  lesion  or 
only  secondary  invaders  is  not  known.  In  other  instances  the  Bacillus 
diphtherias  has  alone  been  found.  The  nature  of  the  lesion  points  to 
the  action  of  a  specific  infection. 

Symptoms. — The  site  of  the  disease  is  usually  the  inner  side  of  one 
or  both  cheeks.  The  gangrenous  process  usually  begins  as  a  small, 
inflamed,  infiltrated  area  in  the  mucous  membrane  opposite  the  teeth. 
Localized  destruction  of  tissue  follows,  and  this  process  extends  with 
great  rapidity  until  the  tissue  sloughs  away  in  masses.  The  parts 
for  some  distance  around  the  ulcer  become  hard,  infiltrated,  and  dis- 
colored, presenting  an  inflamed,  edematous  look.  After  two  or  three 
days  a  discolored,  ecchymosis-like  area  may  be  noticed  on  the  outer 
side  of  the  cheek,  corresponding  in  location  to  the  gangrenous  process 
within.  At  this  point  the  ulcer  soon  perforates.  The  destruction  of 
tissue  continues  quite  symmetrically  around  the  ulcer  until  the  whole 
cheek  is  destroyed.  The  gangrenous  process  not  infrequently  involves 
the  bony  structure,  causing  necrosis  of  the  jaw,  with  loosening  and 
falling  out  of  the  teeth.  A  symptom  which  will  never  fail  and  can 
never  be  forgotten  by  one  who  has  seen  even  one  of  these  cases  is  the 
almost  unbearable  stench  which  emanates  from  the  patient.     When 


GEOGRAPHIC    TONGUE  167 

the  hands  or  the  fingers  of  the  physician  or  nurse  come  in  contact  with 
the  gangrenous  slough,  it  is  almost  impossible  to  remove  or  neutralize 
the  disgusting  odor.  The  disease  usually  occurs  in  weakly,  marantic 
children,  who  die,  ordinarily,  from  exhaustion  and  sepsis  within  ten 
days  or  two  weeks  from  the  onset  of  the  disease.  Hemorrhage  is 
rarely  a  complication.  The  disease  is  usually  fatal,  even  under  the 
best  management. 

Treatment." — The  treatment  pursued  has  consisted  in  the  use  of 
free  cauterization  with  nitric  acid,  chemically  pure,  and  the  application 
of  disinfectant  wet  dressings  of  bichlorid  1  :  2000,  saturated  solution  of 
boric  acid,  or  equal  parts  of  alcohol  and  water.  The  dilute  alcohol  is 
apparently  more  effective  in  staying  the  progress  of  the  disease  than  is 
either  the  bichlorid  or  the  boric-acid  solution.  On  account  of  its  rapid 
evaporation,  the  alcohol  should  be  applied  on  two  or  three  layers  of 
lint  and  covered  with  rubber  tissue.  Even  then  frequent  renewals  are 
required.  Hydrogen  dioxid  may  be  used  to  cleanse  the  ulcer,  both 
before  and  after  perforation. 

FISSURES  OF  THE  LIPS 

Deep  cracks  and  fissures  in  the  lips  are  of  quite  frequent  occurrence 
among  children.  Usually  the  lower  lip  is  involved,  and  in  many  of  the 
cases  there  is  but  one  deep  fissure  and  that  at  about  the  middle  of  the 
lower  lip.  Marasmic,  ill-conditioned  children  are  the  most  frequent 
sufferers.  The  fissures  bleed  easily  and  occasion  considerable  pain 
during  nursing.     As  a  result,  less  food  is  taken  than  the  child  requires. 

Treatment. — If  the  fissure  is  deep,  a  50  per  cent,  solution  of  nitrate 
of  silver  should  be  applied  at  the  commencement  of  the  treatment. 
This  is  to  be  followed  by  frequent  applications — three  or  four  times 
daily — of  a  25  per  cent,  solution  of  ichthyol.  Healing  is  usually 
prompt,  requiring  but  a  few  days.  If  the  mucous  membrane  of  the 
lip  generally  is  dry  and  fissured,  as  in  cases  of  prolonged  illness  with 
fever,  the  frequent  use  of  a  5  per  cent,  boric-acid  ointment,  made  with 
cold-cream  as  a  base,  will  be  of  material  assistance  in  controlling  the 
condition. 

GEOGRAPHIC  TONGUE 

The  condition  known  as  a  "geographic  tongue"  consists  of  distinct, 
smooth,  reddish  patches  on  the  tongue's  surface,  surrounded  by  a 
light. grayish,  narrow,  raised  border.  The  smooth  surfaces  comprising 
the  involved  areas  are  devoid  of  epithelium;  the  borders  are  composed 
of  hypertrophied  papillae  which  take  on  a  grayish  color,  making  a  dis- 
tinct framework  for  the  reddish  areas,  which  are  almost  always  cres- 
centic  in  shape.  This  peculiar  marking  has  given  rise  to  the  term 
"ringworm  of  the  tongue. "  Geographic  tongue  is  seen  most  frequently 
in  children  under  three  years  of  age,  and  occurs  as  often  among  the 
strong  and  vigorous  as  among  the  delicate  and  weakly.  The  condition 
is  usually  discovered  by  the  mother,  who,  with  much  agitation,  brings 


168  THE    PRACTICE    OF    PEDIATRICS 

the  child  to  the  physician.  It  does  not  appear  to  be  due  to  and  is 
usually  not  associated  with  any  disturbance  of  the  gastro-enteric  tract. 
That  portion  of  the  tongue  which  is  not  involved  appears  perfectly 
normal. 

Treatment. — Treatment  of  geographic  tongue  is  unnecessary,  as  the 
condition  causes  no  symptoms  and  apparently  is  independent  of  any 
disease.  It  is  my  custom  to  assure  mothers  that  the  condition  is  of  no 
consequence.  It  usually  disappears  in  a  few  months.  I  have  known 
a  case  to  last  for  a  year. 

ULCERATIONS  AND  FISSURES  AT  THE  ANGLE  OF  THE  MOUTH 

Ulcerations  and  fissures  at  the  angle  of  the  mouth  are  by  no  means 
uncommon  in  delicate  and  marasmic  infants.  While  ulceration  in  this 
location  is  one  of  the  manifestations  of  congenital  syphilis,  such  ulcers 
are  not  necessarily  syphilitic.  The  condition,  however,  is  of  sufficient 
importance  to  require  treatment,  because  the  affection  is  so  painful 
as  to  prevent  the  taking  of  adequate  nourishment.  Painting  the  fissure 
with  a  25  per  cent,  solution  of  ichthyol  every  three  hours  during  the 
day  will  insure  prompt  healing. 

HARELIP  AND  CLEFT-PALATE 

Harelip  is  a  vertical  cleft  in  the  upper  lip  resulting  from  arrested 
embryonic  development.  This  defect  may  or  may  not  be  associated 
with  cleft-palate,  and  varies  from  a  slight  indentation  in  the  border  of 
the  lip  to  a  deep  fissure,  which  may  be  bilateral,  extending  into  the 
nostril,  and  compHcated  by  non-union  of  the  palate.  In  any  case 
the  deformity  will  be  easily  understood  if  we  recall  that  the  normal 
development  of  the  face  depends  upon  the  union  of  the  central  or 
frontonasal  process  with  the  two  lateral  superior  maxillary  processes. 
Posteriorly,  this  union  is  completed  in  the  median  line  of  the  palate, 
and  anteriorly,  on  either  side  external  to  the  incisors,  in  the  soft 
parts  beneath  the  nostril. 

Etiology. — ^The  malformation  is  more  frequent  in  males  than  in 
females,  and  in  some  instances  can  be  ascribed  to  heredity.  Not  in- 
frequently, with  cleft-palate,  other  congenital  defects  coexist.  The 
true  cause  of  the  arrest  in  development  is  unknown. 

Varieties.^ — Both  harehp  and  cleft-palate  may  be  complete  or  in- 
complete, unilateral  or  bilateral.  When  the  harelip  is  double,  cleft- 
palate  also  almost  always  exists.  Median  hare-lip  is  of  exceptional 
occurrence. 

Symptoms. — The  character  of  these  deformities  is  wholly  apparent. 
In  the  simple  forms  of  harelip  the  disadvantages  may  be  merely  cos- 
metic. When  there  is  a  cleft  in  the  palate,  however,  suckling  will 
be  interfered  with,  deglutition  will  be  difficult,  and  if  the  child  goes 
untreated  and  survives,  articulation  will  be  imperfect. 

Treatment. — The  treatment  of  both  harehp  and  cleft-palate  is  es- 
sentially surgical.     The  former  defect,  if  uncompUcated,  may  usually 


THE    TEETH  169 

be  satisfactorily  obliterated  by  an  operation  of  the  Konig  or  Nelaton 
type.  Cleft-palate  offers  more  serious  obstacles.  Brophy  secures  an 
approximation  of  the  edges  of  the  cleft  by  the  gradual  tightening  of 
silver-wire  sutures  traversing  two  lead  plates,  each  of  which  is  fitted 
to  the  lateral  portions  of  the  alveolar  arch.  The  operation  on  the 
soft  parts  is  deferred  until  the  child  is  fourteen  to  eighteen  months  of 
age.  When  the  cleft  is  small,  this  procedure  may  be  excluded  in  favor 
of  a  more  direct  method.  An  operation  during  the  first  months  of  life 
involves  considerable  risk,  but  offers  better  possibilities  for  good 
development  of  the  nasopharynx  than  an  operation  deferred  until  the 
third  or  fourth  year,  after  the  growth  of  the  teeth.  The  appropriate 
course  to  adopt  in  any  case  should,  therefore,  be  left  to  the  surgeon. 
In  young  infants  with  cleft-palate,  spoon-feeding  or  gavage  is  fre- 
quently necessary.  Good  results  in  some  cases  are  reported  to  have 
followed  the  use  of  a  special  nipple  with  a  flange  on  either  side,  designed 
to  bridge  over  the  fissure  in  the  palate. 

THE  TEETH 

Twenty  teeth  comprise  the  first  set.  In  the  well  child  the  first 
tooth  usually  appears  between  the  sixth  and  the  eighth  months;  the 
first  teeth  may,  however,  in  perfectly  normal  cases,  come  earlier  or 
much  later.  I  have  known  well,  vigorous  children  who  did  not  get  a 
tooth  until  the  thirteenth  month.  The  first  teeth  are  usually  the  two 
lower  central  incisors.  The  four  upper  incisors  and  the  two  lower  lateral 
incisors  appear  normally  between  the  eighth  and  the  tenth  months. 
The  first  four  molars  appear  between  the  twelfth  and  the  fifteenth 
months;  the  four  canines  between  the  eighteenth  and  the  twenty- 
fourth  months;  the  four  posterior  molars,  which  complete  the  first 
set,  between  the  twenty-fourth  and  the  thirtieth  months.  This  regu- 
larity in  the  appearance  of  the  teeth  is  by  no  means  constant,  even  in 
well  children.  I  have  repeatedly  seen  the  upper  central  incisors  cut 
first,  and  in  several  instances  the  upper  lateral  incisors  have  appeared 
first.  In  delayed  dentition  in  rachitis  and  other  forms  of  malnutrition, 
the  teeth  are  very  apt  to  appear  irregularly.  In  a  markedly  rachitic 
dispensary  patient  the  molars  were  the  first  teeth  cut. 

Care  of  the  Teeth. — As  soon  as  the  teeth  appear  they  require 
attention.  Until  the  second  year  is  reached  the  mouth  should  be 
washed  out  at  least  twice  a  day  with  a  solution  of  boric  acid — ^^ 
ounce  to  a  pint  of  water.  This  can  best  be  done  by  means  of  ab- 
sorbent cotton  wound  around  the  tip  of  a  clean  index-finger  and  after- 
ward dipped  in  the  solution,  which  should  be  applied  with  gentle 
friction  to  the  gums  and  teeth.  When  a  child  is  two  years  old,  it  is 
well  to  begin  the  use  of  a  soft  tooth-brush  and  a  simple  tooth-powder 
composed  of  the  following  ingredients: 

I^     Precipitated  chalk 5  j 

Bicarbonate  of  soda 5  J 

Oil  of  wintergreen q.  s. 


170  THE    PRACTICE    OF    PEDIATRICS 

The  child  should  also  be  instructed  as  to  the  proper  use  of  a  quill 
toothpick.  The  teeth  of  every  child  over  two  years  of  age  should  be 
examined  by  a  dentist  every  six  months.  Cavities  discovered  in  the 
first  teeth  should  be  filled  with  a  soft  filling. 

The  milk  teeth  are  lost  between  the  sixth  and  the  eighth  years. 
They  should  not  decay,  but  fall  out  or  be  forced  out  by  the  second  set. 

The  Permanent  Teeth. — The  permanent  set  comprises  32  teeth. 
The  second  dentition  begins  about  the  sixth  year,  and  is  usually  com- 
pleted about  the  twentieth  year,  although  it  may  be  delayed  several 
years.     The  permanent  teeth  appear  in  somewhat  the  following  order: 

First  molars sixth  year. 

Central  incisors sixth  to  seventh  year. 

Lateral  incisors seventh  to  eighth  year. 

First  bicuspids ninth  to  tenth  year. 

Second  bicuspids ninth  to  tenth  year. 

Canines eleventh  to  twelfth  year. 

Second  molars thirteenth  to  fifteenth  year. 

Third  molars .after  the  eighteenth  year. 

Dentition. — It  is  claimed  that  the  eruption  of  the  teeth  is  a  physio- 
logic process,  and  as  such  is  not  productive  of  harm.  In  normal  well 
babies  this  is  generally  the  case.  There  may  be  a  slight  fever  and  rest- 
lessness, with  loss  of  appetite,  associated  with  the  eruption  of  a  tooth, 
but  the  disorder  is  usually  very  temporary  in  character.  In  delicate 
children,  particularly  in  those  who  teethe  late,  as  in  the  rachitic,  when 
several  teeth  are  cut  at  one  time,  not  a  little  inconvenience  may  be 
caused  by  dentition.  Even  these  patients,  however,  rarely  have  grave 
digestive  disorders.  In  a  large  experience  with  teething  infants  I 
have  known  but  one  in  whom  convulsions  were  apparently  directly 
dependent  upon  dentition.  The  patient  was  a  rachitic,  institution 
child  who  cut  his  first  tooth  at  the  ninth  month,  and  with  each  of  the 
three  succeeding  teeth,  which  were  cut  during  the  next  three  months, 
developed  convulsions  without  any  other  signs  of  illness. 

Temporary  digestive  disorders  are  of  very  frequent  occurrence  in  this 
type  of  child  during  an  active  dentition.  The  child  may  be  restless 
and  irritable  and  perhaps  have  fever  of  a  degree  or  two.  His  digestive 
capacity  is  lessened,  and  if  the  usual  diet  is  continued,  fermentative 
diarrhea  results,  which  may  be,  and  often  is,  the  starting-point  of  grave 
intestinal  disease.  When  it  is  apparent  that  the  child's  generally  good- 
natured,  daily  habit  of  life  is  being  unfavorably  influenced  by  dentition, 
the  food  should  temporarily  be  reduced,  particularly  if  the  weather  is 
hot. 

Breast  babies  may  be  given  water  before  each  nursing  so  as  to  re- 
duce the  capacity  for  milk.  For  the  bottle-fed  two  or  three  ounces  of 
the  food  mixture  may  be  removed  from  each  bottle,  replacing  the 
amount  with  boiled  water. 

That  cough,  respiratory,  and  skin  diseases  are  immediate  results 
of  dentition  is  without  foundation.  During  active  dentition,  when  the 
gums  are  distended  and  swollen  from  pressure,  relief  will  often  be 
furnished  promptly  by  rubbing  through  the  prominent  points  of  the 


MALFORMATION    OF    THE    ESOPHAGUS  171 

tooth  with  a  clean  towel  over  the  index-finger.  Lancing  alone  may  be 
performed,  but  unless  the  tooth  is  well  advanced,  it  is  quite  possible 
that  the  gums  will  reunite  over  the  tooth,  forming  a  cicatrix  which  will 
make  the  eruption  more  difficult  than  before.  If  a  week  or  ten  days' 
discomfort  can  be  obviated  by  assisting  a  tooth  through  the  gum,  I 
fail  to  see  any  contraindication  to  such  a  procedure. 

MALFORMATION  OF  THE  ESOPHAGUS 

Malformation  of  the  esophagus  is  of  infrequent  occurrence,  and 
when  present,  is  usually  accompanied  by  other  congenital  deformities. 
In  most  instances  the  differentiation  of  the  esophagus  from  the  trachea 
and  bronchi,  in  the  metamorphosis  of  the  embryonic  foregut,  has  been 
incomplete. 

The  list  of  possible  abnormalities  includes  the  following: 

(a)  Total  absence  of  the  esophagus. 

(6)  Diesophagus,  involving  partial  or  complete  reduplication  of  the 
esophagus. 

(c)  Esophagotracheal  fistula,  with  or  without  obliteration  of  the 
lumen  of  the  esophagus  in  a  portion  of  its  extent. 

(d)  Division  of  the  esophagus  into  upper  and  lower  non-communi- 
cating pouches. 

(e)  Congenital  stenosis. 
(/)  Congenital  dilatation. 

The  symptoms  caused  by  these  conditions  depend  on  the  obstacles 
opposed  to  deglutition.  Regurgitation  of  food  and  accumulated 
mucus  is  constant,  accompanied  by  suffocative  attacks  due  to  the 
entrance  of  material  into  the  respiratory  tract.  Congenital  dilatation 
above  the  diaphragm  may  produce  the  symptom  of  rumination. 

In  a  large  majority  of  the  cases,  congenital  malformation  of  the 
esophagus  results  in  death  before  the  tenth  day  from  asphyxia,  aspira- 
tion pneumonia,  or  starvation. 

Gastrostomy  offers  the  only  possible  means  of  prolonging  the  pa- 
tient's  life,  till  surgery  directed  at  the  primary  defect  can  justifiably 
be  attempted. 

An  autopsy  on  an  infant  a  few  days  old  referred  by  me  to  the 
Babies'  Hospital  showed  that  the  trachea  communicated  with  the 
esophagus  just  above  the  bifurcation. 

The  esophagus  was  normal  at  its  upper  portion,  dilated  lower  down, 
and  formed  a  blind  diverticulum  which  ended  below  the  level  of  the 
tracheal  bifurcation.  Above  the  diverticulum  the  esophagus  com- 
municated with  the  trachea  through  an  opening  in  its  anterior  wall. 
Below  the  diverticulum  the  esophagus  was  smaller  in  caliber  than 
normal,  but  it  was  pervious  and  communicated  with  the  stomach.  A 
probe  could  be  passed  upward  through  the  esophagus  into  the  larynx. 


V.   DISEASES  OF  THE  STOMACH,  INTESTINES,  AND 
PERITONEUM 

THE  STOMACH 

Anatomy  .-^During  fetal  life  the  position  of  the  stomach  is  almost 
vertical,  at  birth  slightly  oblique,  the  obliquity  increasing  with  age. 
At  birth  the  stomach  is  almost  cylindric,  and,  according  to  Pfaundler, 
between  the  time  of  birth  and  the  seventh  month  the  fundus  of  the 
stomach  increases  to  fully  twice  its  original  length,  so  that  at  about 
the  end  of  infancy  the  stomach  lies  in  a  somewhat  oblique  position, 
passing  from  behind  forward  and  downward.  The  diaphragm  is  pene- 
trated by  the  esophagus  at  about  the  level  of  the  ninth  dorsal  vertebra, 
while  the  cardia  is  about  on  a  level  with  the  tenth.  The  pylorus, 
though  usually  situated  in  the  median  line,  may  occasionally  be  found 
to  the  right  of  it. 

Capacity. — The  capacity  of  the  infant's  stomach  is,  even  up  to  the 
present  day,  a  subject  of  more  or  less  speculation,  due,  no  doubt,  to 
the  fact  that  during  life  aspirations  are  unreliable  on  account  of  the 
fact  that  food  passes  almost  immediately  into  the  duodenum,  and 
methods  of  experiment  on  the  cadaver  require  an  amount  of  pressure 
(14  to  30  c.c.  of  water)  that  does  not  exist  in  the  normal  state 
during  life.  The  stomach  undergoes  a  systolic  contraction  after 
death,  and  thus  the  distention  with  fluids  is  artificial. 

The  absolute  capacity,  according  to  Holt,  Rotch,  Pfaundler,  and 
Fleishmann,  varies,  depending  on  the  method  of  examination  employed. 
According  to  Holt's  observations  based  on  postmortem  examinations 
of  91  infants,  the  capacity  at  birth  is  1^^  ounces;  at  three  months, 
43-^  ounces;  at  six  months,  6  ounces;  at  twelve  months,  9  ounces. 

Gastric  Digestion. — Digestion  in  the  stomach  is  not  so  important 
in  the  infant  as  in  the  adult.  The  function  of  the  infant's  stom- 
ach is  mainly  that  of  a  reservoir,  the  digestive  processes  being  only 
preliminary.  The  principal  change  in  the  milk,  so  far  as  the  stomach  is 
concerned,  occurs  in  connection  with  the  casein  curd,  and  up  to  the 
present  time  it  is  well  established  that  protein  digestion  in  the  stomach 
does  not  go  beyond  the  stage  of  peptone  formation.  Pepsin  is  found  in 
large  amounts  in  the  infant's  stomach,  and,  according  to  some  observers, 
occurs  as  early  as  the  fourth  month  of  fetal  life.  The  reaction  of  the 
stomach-contents  is  usually  acid  inside  of  fifteen  minutes  after  ingestion 
of  food,  but  free  hydrochloric  acid  is  not  present  till  thirty  or  forty-five 
minutes  after,  the  reason  being  that  hydrochloric  acid  combines  with 
the  casein  and  milk  salts. 

The  coagulation  of  milk,  which  is  the  first  change  that  it  undergoes, 
is  brought  about  through  the  agency  of  the  rennet  ferment.  The 
casein  coagulum  of  cow 's  and  of  human  milk  is  essentially  different,  the 

172 


ACUTE    GASTRITIS   AND   ACUTE   GASTRIC   INDIGESTION        173 

former  being  a  firm  mass,  containing  in  its  meshes  the  fat  of  the  milk, 
the  latter  being  in  fine  flocculi,  with  little  of  the  fat  of  the  milk,  and 
readily  acted  on  by  the  stomach-juices.  Due  to  the  influence  of  pepsin 
and  hydrochloric  acid,  solution  of  the  coagulum  begins;  this  occurs 
more  rapidly  in  woman's  milk  on  account  of  the  lower  casein  content 
and  the  small  size  of  the  curds.  During  the  first  half-hour  the  fluid 
portion  or  whey  begins  to  leave  the  stomach,  and  at  this  time  a  con- 
siderable portion  may  be  found  in  the  intestine,  and  at  the  end  of  an 
hour  in  a  young  infant  the  stomach  may  often  be  found  empty.  In  a 
bottle-fed  baby  the  coagula  are  larger,  solution  is  retarded,  and  conse- 
quently the  food  is  retained  longer.  If  the  milk  is  boiled,  solution  is 
more  rapid  and  gastric  retention  lessened.  Some  observers  believe  a 
fat-splitting  ferment  to  be  present,  but  this,  if  present,  plays  but  a 
small  role  in  digestion. 

Motility. — The  duration  of  digestion  varies  of  necessity  with  the 
age  of  the  infant  and  the  composition  of  the  food.  In  general  terms 
it  may  be  stated  that  in  breast-fed  infants  digestion  is  completed  in  one 
and  one-half  to  two  hours;  in  artificially  fed  infants  taking  raw  milk, 
in  about  one  to  two  hours  longer;  and  in  those  taking  boiled  milk,  in  a 
little  less  time. 

Cannon  has  shown  that  an  acid,  reaction  of  the  contents  of  the 
pyloric  portion  causes  the  pylorus  to  open,  while  an  acid  reaction  in  the 
duodenum  causes  it  to  remain  closed.  After  the  coagulation  of  the 
casein  of  the  milk  the  whey  is  readily  acidified  and  passes  the  pylorus 
first,  together  with  the  carbohydrates.  As  the  proteid  requires  a 
longer  time  to  combine  with  the  acid  of  the  stomach  it  is  some  time 
before  free  acid  is  present,  and  the  exit  of  the  proteid  from  the  stomach 
is,  therefore,  delayed.  The  fatty  acids  and  neutral  fats  are  the  last  to 
pass  the  pylorus,  because  of  the  longer  time  required  for  the  fatty  acids 
to  be  neutralized  by  the  duodenal  secretions;  and  the  pylorus,  there- 
fore, remains  closed  because  of  duodenal  activity.  The  opening  and 
closing  of  the  pylorus,  according  to  these  investigations,  depends 
chiefly  on  the  reaction  of  the  gastric  contents,  which  is  the  most  vital 
factor  in  the  motor  activity  of  the  stomach. 

ACUTE  GASTRITIS  AND  ACUTE  GASTRIC  INDIGESTION 

Not  a  little  confusion  exists  respecting  the  differentiation  of  acute 
gastritis  and  acute  gastric  indigestion.  Cases  of  gastric  indigestion  are 
often  diagnosed  as  gastritis.  In  fact,  acute  gastritis  in  children  is  a  very 
rare  condition,  while  acute  gastric  indigestion  is  very  frequent.  Acute 
gastritis  in  the  young  is  usually  due  to  the  ingestion  of  corrosive  or 
irritant  drugs.  Food,  unsuitable  in  character  or  quantity,  or  food 
which  may  have  undergone  chemical  or  bacterial  change,  may  produce 
pronounced  vomiting,  usually  transient  in  character.  Inflammation 
of  the  mucous  membrane  of  the  stomach  may  be  produced  in  this 
way,  but  according  to  autopsy  findings  it  is  most  unusual. 

Cases  of  persistent  vomiting  which  are  often  diagnosed  as  gastritis 


174  THE    PRACTICE    OF    PEDIATRICS 

not  infrequently  prove  to  be  of  cerebral  or  uremic  origin,  or  due  to 
some  form  of  intestinal  obstruction,  or  are  cases  of  recurrent  vomiting. 

Autopsies  on  infants  dying  from  acute  gastro-enteric  diseases, 
such  as  cholera  infantum,  rarely  show  any  stomach  lesion,  although 
there  may  have  been  persistent  vomiting  for  two  or  three  days. 

Acute  Gastric  Indigestion. — Acute  gastric  indigestion  is  manifested 
in  sudden  repeated  vomiting,  often  with  fever,  always  with  prostration, 
and  with  apparent  disgust  for  food.  The  temperature  may  be  high — 
104°  to  105°F. — or  normal  throughout.  After  a  few  hours  there  will 
often  be  evidence  of  bowel  disturbance.  The  stools  will  be  undigested, 
greenish  in  color,  and  contain  a  moderate  amount  of  mucus.  There 
may  be  moderate  abdominal  distention.  In  fact,  the  symptoms  other 
than  that  of  emesis  are  of  a  very  indifferent  character. 

Treatment. — A  high  enema  should  always  be  given  as  the  initial 
treatment  in  any  illness  of  any  nature  in  which  there  is  acute  vomiting 
with  an  absence  of  free  bowel  action.  If  the  vomiting  is  continued,  the 
management  of  the  case,  regardless  of  the  exciting  cause,  is  to  wash 
out  the  stomach  at  least  once  and  to  give  no  food  by  mouth.  If  the 
case  is  of  more  than  twelve  hours '  duration  in  an  infant  or  twenty-four 
hours'  in  an  older  child,  colon  flushings  should  be  carried  out  to  supply 
fluids  to  the  organism  (p.  795).  A  means  of  much  value,  both  in  in- 
fants and  in  the  older  children,  which  I  use  with  great  frequency,  is 
a  solution  of  bicarbonate  of  soda,  5  grains  in  6  ounces  of  water,  given 
hot  in  teaspoonful  doses  at  intervals  of  a  very  few  minutes. 

Diet. — After  twelve  or  twenty-four  hours'  abstinence  from  food, 
small  quantities  of  water  or  some  very  weak  food  may  be  given  ten- 
tatively if  the  child  craves  it.  Whey,  skimmed  or  diluted  milk,  barley- 
water,  weak  tea,  chicken,  or  mutton  broth,  may  be  tried  in  teaspoonful 
doses  every  half  hour.  Usually  cold  foods  will  be  retained  better  than 
those  that  are  heated.  If  the  food  or  water  is  rejected,  a  further  stomach 
rest  of  from  eight  to  twelve  hours  may  be  ordered  before  the 
feeding  is  resumed. 

Treatment  of  Protracted  Cases. — In  the  protracted  cases,  the  stom- 
ach should  be  washed,  at  least  once  daily,  with  a  5  per  cent,  solution 
of  bicarbonate  of  soda.  It  is  never  wise,  in  the  event  of  vomiting, 
to  attempt  forced  feeding,  as  nothing  will  be  gained;  in  fact  the  vomit- 
ing may  be  continued  indefinitely,  and  chronic  gastric  indigestion 
established,  as  a  result  of  injudicious  attempts  at  feeding.  For  the 
persistent  vomiting  of  infants,  gavage  (p.  790)  may  also  be  used.  I 
have  employed  this  successfully  in  a  great  many  cases  of  persistent 
gastric  indigestion  with  vomiting.  A  food  which  is  rejected  when  swal- 
lowed will  oftentimes  be  retained  when  put  into  the  stomach  through 
a  tube.  If  nourishment  cannot  be  retained  after  thirty-six  hours, 
when  given  by  the  natural  method  or  by  gavage,  it  is  best  to  begin 
feeding  by  the  bowel,  using  completely  peptonized  milk,  at  intervals 
of  from  six  to  eight  hours,  in  quantities  of  from  two  to  four  ounces  for 
young  infants  and  from  six  to  twelve  ounces  for  children  from  eight  to 
ten  years  of  age.     Applications  of  heat  or  counterirritation  over  the 


CHRONIC   GASTRIC   INDIGESTION    (CHRONIC   GASTRITIs)        175 

stomach  area  have  been  of  very  httle  service.  I  have  treated  hundreds 
of  these  cases  of  acute  indigestion  with  different  forms  of  medication, 
including  calomel,  small  doses  of  ipecac,  oxalate  of  cerium,  opium,  etc., 
and  have  been  far  more  impressed  with  their  uselessness  than  with  their 
beneficial  influence.  Drugs  oftentimes  get  credit  to  which  they  are  not 
entitled  for  the  improvement  of  the  patient.  A  child  has  an  acute 
attack  of  indigestion  with  repeated  vomiting.  He  is,  perhaps,  given  an 
enema,  his  food  is  stopped,  a  certain  drug  is  given  in  small  quantities  of 
water,  he  recovers,  and  the  drug  gets  the  credit.  He  probably  would 
have  recovered  more  quickly  without  the  drug.  As  a  rule,  the  use  of 
drugs,  or  even  a  small  quantity  of  water,  when  given  early,  will  prolong 
the  attack. 

An  enema,  the  recumbent  position,  and  the  withholding  of  food, 
with  nourishment  or  fluids,  such  as  normal  salt  solution,  by  the  bowel, 
have  given  me  my  best  results.  When  the  child  craves  food  and  asks 
for  water  after  an  abstinence  of  several  hours,  feeding  may  be  tried, 
but  the  fact  that  he  asks  for  it  is  by  no  means  a  guarantee  that  what  is 
given  will  be  retained. 

Treatment  for  Persistent  Vomiting. — In  pronounced,  urgent,  frequent 
vomiting,  morphin  hypodermically  may  be  required.  The  morphin 
should  be  guarded  by  atropin  and  given  in  doses  of  )^o  to  J^o  grain  for 
a  child  one  year  old,  to  Ko  grain  for  a  child  from  eight  to  twelve  years 
old.  The  relation  of  the  dose  of  morphin  to  that  of  the  atropin  should 
be  as  1  is  to  Ko-  Thus,  a  child  who  is  given  }io  grain  morphin  should 
have  combined  with  it  3^^oo  grain  atropin;  with  Ko  grain  morphin  there 
should  be  given  Koo  grain  atropin. 

It  will  rarely  be  necessary  to  repeat  the  morphin  more  than  once, 
two  injections  being  given  at  intervals  of  from  four  to  six  hours.  In  all 
cases  the  usual  feedings  must  gradually  be  resumed.  A  trial  of  differ- 
ent foods  will  soon  show  which  will  best  be  retained. 

CHRONIC  GASTRIC  INDIGESTION  (CHRONIC  GASTRITIS) 

Chronic  gastritis  is  seen  most  frequently  in  comparatively  young 
infants,  and  is  often  associated  with,  or  is  a  cause  of,  marasmus  and 
malnutrition. 

Symptoms. — Vomiting  and  regurgitation  of  food  are  the  predomi- 
nant acute  manifestations  of  the  disorder,  which,  untreated,  interferes 
seriously  with  the  nutrition  of  the  patient.  The  condition  is  almost 
invariably  a  result  of  slight  but  persistent  error  in  feeding — errors  too 
small  to  make  the  child  violently  ill,  but  sufficient  to  keep  the  stomach 
in  a  constant  state  of  unrest. 

Pathology. — The  lesions  in  these  cases  are  insignificant.  There 
may  be  some  superficial,  localized  congestion  at  the  pyloric  end  of  the 
stomach — there  may  be  destruction  of  the  superficial  epithelium  and 
infiltration  of  the  mucosa  with  round-cells. 

Treatment. — The  management  consists  in  daily  stomach-wash- 
ings, sometimes  for  a  long  period,  and  an  adaptation  of  the  food  to  the 


176  THE    PRACTICE    OF    PEDIATRICS 

child's  digestive  capacity  (p.  62).  While  there  is  no  one  way  of 
feeding  these  cases,  a  food  of  greatly  reduced  strength  must  always 
be  given,  particularly  when  cow 's  milk  is  used.  As  a  rule,  these  children 
have  a  low  fat  capacity — not  more  than  1,5  per  cent,  can  usually  be 
taken.  Sugar  is  also  badly  borne  by  many  of  these  infants  and  must  be 
given  in  reduced  strength — ^from  3  to  4  per  cent.  only.  Usually  the 
proteids  are  fairly  well  taken  care  of  if  the  function  of  the  stomach 
is  not  compromised  by  too  much  fat  and  sugar.  In  cases  of  children 
under  nine  months  of  age,  a  wet-nurse  may  help  solve  the  problem. 
On  beginning  with  the  wet-nurse,  however,  the  child  should  not  be  al- 
lowed to  get  over  one  or  two  ounces  at  a  nursing,  lest  the  fat  in  the  milk 
continue  the  trouble.  The  remainder  of  the  feeding  is  given  by  the 
bottle.  Granum- water  or  barley-water  No.  1  (see  p.  70)  may  be  used 
in  quantity  sufficient  to  bring  up  the  amount  to  the  number  of  ounces 
required. 

Dilatation  of  the  stomach  is  usually  present,  and  motor  inactivity 
necessitates  stomach-washing,  which  may  be  required  for  several 
months  at  gradually  decreasing  intervals.  Details  of  the  treatment, 
which  relate  largely  to  feeding,  would  necessitate  a  repetition  of  what 
has  been  said  in  the  chapters  on  Malnutrition,  Marasmus,  and  Food 
Adaptation,  to  which  the  reader  is  referred. 

It  is  to  be  remembered  that  in  these  cases  the  feeding  interval  is 
important,  regardless  of  the  age.  Because  of  motor  inactivity,  the 
stomach  requires  a  longer  time  than  the  normal  to  empty  its  contents 
into  the  intestine. 

CHRONIC  DILATATION  OF  THE  STOMACH  IN  INFANTS 

In  children  of  any  age  the  stomach  capacity  may  be  found  greatly 
increased.  I  have  seen  the  holding  capacity  increased  to  two  or  three 
times  the  normal.  Bottle-fed  infants  under  one  year  of  age  furnish 
most  of  the  cases. 

In  the  absence  of  pyloric  stenosis  or  pyloric  spasm  (p.  185)  the  per- 
sistent feeding  of  too  large  quantities  of  food  at  frequent  intervals  is  the 
cause.  It  is  not  at  all  infrequent,  in  cases  of  malnutrition  and  athrep- 
sia,  to  find  the  patients  taking  at  every  feeding  from  two  to  three 
ounces  above  the  normal  stomach  capacity  for  children  of  their  size 
and  weight. 

Symptoms. — Infants  with  dilated  stomachs  almost  invariably  suf- 
fer from  indigestion,  usually  with  the  vomiting  of  milk  curds  and 
mucus,  the  vomiting  generally  taking  place  a  considerable  time  after 
the  feeding,  and  becoming  habitual.  In  marasmus  and  in  the  various 
forms  of  malnutrition  the  stomach  is  usually  more  or  less  dilated. 

Treatment. — Often,  in  these  cases,  the  nourishment  that  has  been 
given  is  of  the  proper  strength,  and  all  that  will  be  required  is  to  reduce 
the  quantity  allowed  and  perhaps  decrease  the  frequency  of  the  feedings. 
The  stomach  should  be  washed  daily  if  the  child  does  not  respond  to 
the  simple  reduction  in  the  amount  of  fluid.     Particularly  is  the 


PTOSIS    AND    DILATATION    OF    THE    STOMACH  177 

stomach  to  be  washed  if  there  is  a  tendency  to  fermentation  in  the 
stomach-contents,  evidenced  by  the  presence  of  gas  in  the  stomach 
and  frequent  eructations  of  sour,  undigested  food  and  mucus.  The 
food  should  contain  a  low  fat  and  a  moderate  amount  of  sugar,  A 
reasonably  high  proteid  may  usually  be  given.  Because  of  the  tend- 
ency to  fermentation,  these  cases  do  badly  on  the  gruel  diluents  also, 
and  these,  if  they  have  formed  a  part  of  the  child 's  diet  are  to  be  dis- 
continued. Small  doses  of  bismuth  subcarbonate,  3  grains,  bicarbonate 
of  soda,  2  grains,  benzoate  of  soda,  1  grain,  two  hours  after  each  feed- 
ing, have  a  decidedly  beneficial  effect.  Hydrochloric  acid  should  not 
be  given,  and  pepsin  is  unnecessary. 

PTOSIS  AND  DILATATION  OF  THE  STOMACH  IN  OLDER  CHILDREN 

This  combination  we  are  finding  in  a  considerable  number  of 
children  who  appear  for  treatment  of  persistent  stomach  derangements. 
A  dilated  stomach,  however,  may  not  be  ptosed.  Our  Roentgen  ray 
studies  of  a  great  many  stomachs  lead  us  to  believe  that  Fig.  11  rep- 
resents the  normal  stomach  for  a  child  four  years  of  age. 

Etiology. — The  condition  in  some  children  is  probably  carried  over 
from  infancy,  being  the  outcome  of  a  defective  pylorus,  and  it  may  re- 
sult from  a  habitual  over-filling  of  the  stomach.  Children  who  have 
the  milk  habit,  who  drink  large  quantities  of  milk  or  water  with  their 
regular  meals,  are  very  apt  to  have  dilated  and  ptosed  stomachs.  The 
carrying  capacity  of  this  organ  is  not  unlimited  and  the  full  meal  of 
solid  food  with  a  considerable  amount  of  milk  or  water,  produces  an 
increase  in  the  weight  of  the  stomach  contents,  with  gradually  result- 
ing enlargement  and  ptosis. 

It  will  probably  be  learned  that  the  cases  of  pyloric  stenosis  of 
infancy  which  apparently  recover  without  operation,  are  sufferers  in 
later  life  from  the  same  condition  in  a  modified  form.  During  the  past 
year  I  have  had  five  patients  over  two  years  of  age  that,  according  to 
a;-ray  demonstrations  after  a  bismuth  meal,  have  shown  various  degrees 
of  pyloric  obstruction. 

After  the  third  year  the  stomach  should  normally  be  empty  in  four 
hours.  In  one  patient  the  stomach  contained  residue  after  ten  hours 
and  did  not  begin  to  empty  for  two  hours.  This  stomach  required 
about  twelve  hours  to  empty  a  bismuth  meal.  I  have  had  six  patients 
in  which  the  stomach  contained  residue  after  six  hours. 

The  Bismuth  Meal. — The  opaque  substance  added  to  the  food  in 
order  to  give  a  contrast  in  the  roentgenogram  is  bismuth  subcarbonate, 
bismuth  oxychlorid  or  barium  sulphate,  especially  prepared  for  a;-ray 
work.  The  opaque  substances  are  usually  used  in  the  preparation  of 
one  part  to  eight  of  food,  for  a  child  four  years  of  age. 

Symptoms. — The  symptoms  of  the  enlarged  stomach  are  quite  simi- 
lar but  vary  in  degrees.  The  appetite  is  invariably  good.  The  child 
demands  a  large  amount  of  food  and  is  very  unhappy  when  the  volume 
is  reduced.  They  have  the  drinking  habit  with  their  meals  abnor- 
mally developed.  A  symptom  with  all  is  the  distention  of  the  stomach 
12 


178 


THE    PRACTICE    OF    PEDIATRICS 


with  gas  and  habitual  eructation  of  gas.     Stomach  pain,  sometimes 
paroxysmal  after  eating,  is  a  very  frequent  complaint. 

In  all  but  one  case  there  was  malnutrition  and  secondary  anemia 
and  in  all  but  one  there  were  periodic  vomiting  attacks  at  rather  in- 


Fig.  11. — Male  four  years  of  age.     Normal  stomach. 

frequent  intervals.  The  sensation  of  stomach  discomfort  and  food 
craving  are  very  constant  symptoms.  In  one  patient,  Fig.  13,  with 
emptying  of  the  stomach  retarded  after  six  hours,  there  was  a  persistent 


PTOSIS    AND    DILATATION    OF    THE    STOMACH 


179 


urticaria  for  which  the  child  was  brought  to  me.     This  child  was  nine 
years  old,  the  urticaria  had  first  appeared  at  the  age  of  two  years. 


Fig.  12. ^Female  aged  three  and  one-half  months.  Entire  stomach  outline  can 
be  made  out  owing  to  the  presence  of  air.  No  bismuth  present.  Roentgenogram 
by  Dr.  L.  T.  LeWald. 


Fig.  14  represents  a  case  of  ptosis  in  a  boy  of  eleven  years,  in  which 
the  stomach  failed  to  empty  in  six  hours.     In  this  child  there  were 


180 


THE    PRACTICE    OF    PEDIATRICS 


vomiting   attacks  every  two  to  three  months  and  a  great  deal  of 
stomach  pain  during  the  seizm'e  and  in  the  intervals. 

Fig.  15  represents  a  greatly  dilated  stomach  of  a  gul  two  years  of 
age.  The  cardiac  end  of  the  stomach  is  filled  with  gas.  The  child 
was  brought  to  me  because  of  frequent  stomach  pain  and  abdominal 
discomfort.     There  was  considerable  abdominal  distention. 


GAS   -> 


«__./3.a"- -» 


Pig.  13. — Female  aged  ten  years.    Ptosis  of  stomach.     Greater  curvature  1 J.^  inches 
below  the  level  of  vunbilicus  (LeWald). 

Treatment. — The  principal  point  in  the  treatment  is  not  to  over- 
load the  stomach  at  any  time.  In  order  to  overcome  this  the  meal  is 
given  with  an  absence  of  fluid  and  the  child  is  made  to  rest  on  its  back 
or  preferably  on  the  right  side  for  an  hour  after  the  morning  and  mid- 
day meal  of  solid  food.  Three  meals  are  given  daily  at  not  less  than 
five-hour  intervals.  Three  hours  after  the  breakfast  and  mid-day 
meal  six  to  eight  ounces  of  milk  or  water  is  given.     The  evening  meal  is 


PTOSIS    AND    DILATATION    OF    THE    STOMACH 


181 


given  in  bed  with  eight  ounces  of  fluid.  The  child  is  made  to  lie  down 
immediately  after.  Upon  awakening  the  following  morning  as  much 
water  is  given  as  the  child  cares  to  drink  and  in  one-half  to  one  hour  the 
breakfast  is  served. 

Such  a  regime  carried  out  for  a  few  months  will  reduce  the  size  of 
the  stomach  if  there  is  no  pyloric  obstruction. 


Fig.  14. — Male  aged  eleven  years.     Ptosisof  stomach  (Le^A'ald). 

In  addition  to  the  above,  children  with  ptosis  are  supplied  with  an 
Aaron  band  with  a  transverse  shelf  so  arranged  as  to  fit  under  the 
ptosed  stomach  and  furnish  support.  In  those  who  suffer  from  accumu- 
lation and  eructation  of  gas  2-grain  doses  of  salicine  are  given  at  meal 
time  or  the  following  prescription  is  ordered: 

I^     Magnesia  carb gr.  xv 

Sodii  bicarb gr.  xx 

Bismuth  sub.  carl) gr.  xxx 

M.  ft.  chart  no  XXX  div.  Sig.     One  fifteen  minutes  before  meals  with  water. 


182 


THE    PEACTICE    OF    PEDIATEICS 


In  cases  of  dilatation  due  to  pyloric  obstruction  operative  proce- 
dure of  pyloroplasty  or  gastro-enterostomy  may  be  required. 


M€RR1LI 


Fig.   15. 


HEMORRHAGE  FROM  THE  STOMACH;  VOMITING  BLOOD 

With  the  exception  of  hemorrhagic  disease  in  the  newly  born,  the  vom- 
iting of  blood  by  infants  has  been  due,  in  my  experience,  to  ulceration  of 


ULCERATION    OF    THE    STOMACH  183 

the  stomach  (p.  183),  to  purpura  fulminans  (Henoch's),  or  to  accidental 
causes.  In  two  of  my  proved  cases,  extensive  ulceration  of  the 
stomach  was  found  at  autopsy.  A  boy  six  years  of  age  died  on  the 
third  day  with  purpura  fulminans.  There  were  profuse  hemorrhages 
from  the  stomach,  from  the  mucous  surfaces,  and  under  the  skin. 
Accidental  sources  include  the  swallowing  of  blood,  which  may  take 
place  as  the  result  of  a  nasal  hemorrhage,  or  from  a  blow  or  fall  causing 
injury  to  the  nose  or  mouth,  or  from  the  presence  of  a  foreign  body  in 
one  of  the  nostrils.  Injury  to  the  pharynx  also  may  be  followed  by 
hemorrhage  sufficient  to  cause  vomiting  if  the  blood  is  swallowed.  A 
case  of  hematemesis  in  a  well-nourished  breast-fed  infant  five  months 
of  age  gave  me  a  great  deal  of  anxiety.  The  vomiting  of  blood  con- 
tinued for  several  days  without  the  slightest  evidence  as  to  its  source. 
This  occurred  two  or  three  times  a  day,  usually  shortly  after  nursing, 
the  quantity  of  blood  being  especially  large  after  the  early  morning 
nursing.  There  were  no  cracks  or  fissures  in  the  mother's  nipples,  nor 
could  blood  be  made  to  exude  from  any  portion  of  the  nipples  on 
reasonably  strong  pressure.  Convinced,  nevertheless,  that  the  source 
must  be  the  breast,  I  applied  a  breast-pump,  making  use  of  as  strong 
suction  as  possible,  and  obtained  milk  with  a  large  mixture  of  blood. 
Evidently  there  had  been  a  rupture  of  some  of  the  smaller  blood-vessels 
in  the  gland  behind  the  nipple.  At  the  first  nursing  the  child  was  very 
hungry  and  tugged  vigorously  at  the  breast,  which  doubtless  explains 
why  the  early  morning  vomiting  showed  the  most  blood. 

In  hematemesis  in  the  newly  born  the  patient  should  have  the  ad- 
vantage of  the  human  serum  or  blood  injections  (p.  160). 

ULCERATION  OF  THE  STOMACH 

Ulceration  of  the  stomach  is  usually  associated  with  marked  gastric 
disturbance,  such  as  occurs  in  gastritis  and  in  the  different  forms  of 
malnutrition. 

Notwithstanding  a  large  autopsy  experience  among  infants  and 
young  children,  I  have  as  yet  to  see  a  perforating  ulcer,  tuberculous  or 
of  other  type.  In  fact,  aside  from  those  in  the  newly  born  I  have  seen 
at  autopsy  only  two  cases  of  ulceration.  In  three  other  cases  the 
diagnosis  of  ulceration  was  made  because  of  hematemesis.  A  child  one 
month  old  repeatedly  vomited  blood,  and  eventually  bled  to  death. 
At  autopsy  about  two  ounces  of  coagulated  blood  were  found  in  the 
stomach.  The  gastric  mucous  membrane  was  the  seat  of  many  ulcers, 
varying  in  size,  none  exceeding  3^16  iiich  in  diameter.  Another  patient, 
three  months  old,  had  chronic  gastro-enteritis  with  occasional  vomiting 
of  blood  and  died  from  exhaustion,  the  autopsy  showing  multiple  small 
ulcers  in  the  mucous  membrane  of  the  stomach.  That  ulcerations, 
even  of  a  mild  degree,  play  any  great  part  in  the  digestive  disorders  of 
infants  and  young  children  is  disproved  by  the  infrequency  of  the  lesion 
at  autopsy. 

In  treating  cases  of  gastric  disorders  by  stomach-washing  it  is  com- 


184  THE    PRACTICE    OF    PEDIATRICS 

paratively  rare  to  find  blood  in  the  water  siphoned  off.  At  rare  inter- 
vals the  water  may  be  tinged  with  blood,  but  the  washings  invariably 
should  be  continued  in  spite  of  this,  as  I  have  never  known  any  severe 
hemorrhage  to  follow.  The  blood  which  appears  under  these  condi- 
tions is  doubtless  from  the  capillaries  of  the  congested  mucous  struc- 
ture, which  are  distended  as  a  result  of  strain. 

Treatment. — In  the  event  of  persistent  vomiting  of  blood  of  small 
or  large  amount,  which  cannot  otherwise  be  accounted  for,  the  walls  of 
the  stomach  are  to  be  regarded  as  the  source  of  the  hemorrhage. 
Under  these  conditions  oral  feeding  should  be  discontinued  and  the 
nutrient  enema  (p.  83)  should  be  brought  into  use.  Bromid  and 
chloral,  or  stimulants  if  necessary,  may  thus  be  given  with  the  food. 
Suprarenal  extract  in  one-grain  doses  should  be  given  hourly  and 
continued  for  twelve  hours  after  the  vomiting  ceases.  After  thirty- 
six  hours  water  may  be  given  in  small  amounts;  and  the  usual  milk- 
mixture  diluted  one-half,  in  small  quantities  of  two  or  three  ounces, 
may  also  be  allowed.  The  normal  diet  should  not  be  resumed  in 
less  than  a  week,  even  in  the  event  of  an  entire  absence  of  vomiting 
during  this  period. 

DUODENAL  ULCER 

Duodenal  ulcer  is  a  very  unusual  disease  in  infants.  In  all,  one 
hundred  cases  have  been  reported.  Holt  found  ninety-one  cases 
reported  in  the  literature.  To  this  he  adds  four  cases  of  his  own  which 
were  observed  at  the  Babies'  Hospital.  Among  1800  autopsies, 
largely  in  children  under  one  year,  the  post-mortem  records  showed  but 
four  that  had  duodenal  ulcer.  More  recently,  Veeder*  has  reported 
five  cases. 

Pathology. — The  lesions  as  described  by  Veeder  are  as  follows: 
the  ulcers  may  be  single  or  multiple,  and  vary  from  small  areas  of 
superficial  necrosis  to  cleanly  punched-out  ulcers  which  involve  all  the 
layers  of  the  intestinal  wall  and  which  in  a  few  cases  have  perforated, 
with  a  resulting  peritonitis.  They  are  found  between  the  pylorus  and 
the  ampulla  and  are  most  commonly  situated  just  beyond  the  pyloric 
ring.     The  ulcers  are  usually  located  on  the  posterior  wall. 

Age. — The  great  majority  of  the  cases  reported  occurred  in  infants 
under  six  months  of  age.  The  lesion  has  been  found  post-mortem,  in 
most  of  the  cases  not  being  recognized  during  life.  In  Veeder's  cases 
proven  by  autopsy  the  diagnosis  of  duodenal  ulcer  was  made  ante- 
mortem  in  one  only. 

Symptoms. — The  only  symptom  of  value  is  the  presence  of  blood 
mixed  with  the  stools.  When  this  occurs  in  a  marantic  infant,  ulcer 
should  always  be  suspected.  We  would  then  have  to  differentiate  from 
peptic  ulcers,  polypus  of  the  lower  intestine,  fissure  of  the  rectum, 
intussusception,  ulcerative  colitis,  melena  neonatorum  and  diverticula. 
It  will  be  observed  that  the  diagnosis  of  duodenal  ulcer  is  not  a  simple 

*  Amer.  Journal  Diseases  of  Children,  vol.  vi,  pp.  382-393. 


PYLORIC    STENOSIS  185 

matter,  and  it  is  altogether  probable  that  in  the  future,  diagnosis  of 
the  disease  will  continue  to  be  made  post-mortem,  particularly  as  in 
some  of  the  cases  no  hemorrhage  occurred  at  any  time. 

THE  MANAGEMENT  OF  VOMITING  BABIES 

The  baby  who  habitually  vomits  or  regurgitates  his  food  is  one  of 
the  most  troublesome  patients  with  whom  we  have  to  deal. 

In  such  cases  the  possibility  of  existing  pyloric  stenosis  must  be 
excluded.  My  best  results,  in  feeding  these  habitual  vomiting  children, 
have  been  gained  by  the  use  of  cereal  decoction  and  a  fat-free  milk. 
One  ounce  of  barley-flour  to  the  pint  of  water  is  cooked  for  thirty  min- 
utes, and  water  added  to  make  one  pint  at  the  completion  of  the  boihng. 
The  child  is  fed  one-third  skimmed  milk  to  two-thirds  barley-water,  or 
one-half  skimmed  milk  to  one-half  barley-water,  depending  upon  the 
patient's  age  and  condition.  Unless  the  child  is  very  young,  the  in- 
terval between  feedings  should  be  three  hours  or  longer,  and  he  should 
be  kept  absolutely  quiet  for  one  and  one-half  hours  after  feeding.  The 
handling  and  tossing  about  of  the  vomiting  child  is  one  of  the  best  ways 
of  keeping  up  the  trouble.  If  constipation  results  from  such  a  diet, 
magnesia  in  sufficient  amount  may  be  added  to  the  daily  ration. 

It  is  not  to  be  expected  that  a  patient  will  grow  on  the  above  diet. 
When  the  vomiting  is  controlled,  the  food  strength  may  be  advanced 
by  the  use  of  whole  milk,  and  later  by  the  addition  of  milk-sugar.  The 
addition  of  20  grains  of  bicarbonate  of  soda  to  the  day's  ration  is  of 
decided  benefit  in  very  troublesome  cases. 

By  some  infants  fresh  cow's  milk  will  not  be  tolerated,  even  in  very 
weak  dilution.  In  such  instances  I  have  been  successful  in  using  an 
evaporated  or  condensed  milk  to  which  cane-sugar  has  not  been  added. 
From  1  dram  to  one-half  ounce  is  added  to  the  amount  of  barley-water 
given  at  one  feeding.  Such  a  milk  is  put  up  by  the  Borden  Condensed 
Milk  Co.,  and  is  known  on  the  market  as  Peerless  Brand  Evaporated 
Milk.  As  the  preservative,  cane-sugar,  is  not  a  part  of  the  preparation, 
the  contents  of  a  can  may  be  used  for  only  one  day. 

Stomach-washing. — Nearly  all  habitually  vomiting  children  will 
improve  more  rapidly  if  they  have  a  stomach-washing  every  day  for  a 
week,  and  every  two  or  three  days  thereafter,  as  may  be  necessary. 
For  Vomiting  in  Rumination  see  p.  220. 

PYLORIC  STENOSIS 

That  true  pyloric  stenosis  is  a  congenital  condition  is  accepted  by 
most  authors.  There  are  three  types  of  the  disease  in  infants — the 
spasmodic,  the  hypertrophic,  and  the  combined  type. 

Age  and  Sex  Incidence. — In  this  disease  the  age  is  of  great  impor- 
tance as  a  diagnostic  point.  Of  38  patients  reported  by  Still,  one  be- 
gan to  vomit  within  twenty-four  hours  after  birth  and  6  others  within 
the  first  week.     Pfaundler  found  that  the  first  vomiting  indicating  the 


186 


THE    PRACTICE    OF    PEDIATRICS 


onset  of  the  disease  was  between  the  fourth  and  fourteenth  days  in  50 
per  cent,  of  the  cases;  from  the  second  to  third  week  in  25  per  cent.; 
and  from  the  third  to  sixth  week  in  25  per  cent.  In  my  own  cases,  39 
in  number,  the  vomiting  never  appeared  later  than  the  sixth  week. 
The  symptoms  may  begin  a  few  hours  or  days  after  birth,  or  they  may 
not  appear  until  the  third  or  fourth  week;  occasionally  not  until  the 
second  month,  and  very  rarely  not  until  a  later  date,  according  to  re- 
corded cases.  Instances  of  hypertrophy  and  stenosis  of  the  pylorus 
coming  on  in  adult  life  have  been  frequently  recorded,  and  these  may 
probably  be  due  to  a  persistence  of  the  condition  from  early  life. 
According  to  Ibrahim's  investigations  of  266  cases,  the  total  number  of 
cases  shows  a  rapidly  ascending  curve  in  the  first  month  and  a  reduced 
frequency  with  advancing  age. 


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f 

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1 

1 

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/ 

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'    5 

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0 

ihtoJ  numbeh 
Of  cases 

290 

260 
S.'fO 

ZZO 

ZOO 
l9Q 
160 
/Uo 
tZo 
100 
80 

bo 
40 
20 

Weeks  of  Life  — 

Fig.   16.— Drawn  in  accordance  with  Ibrahim's  266  cases  (Pfaundler  and  Schloss- 

man's  System,   1912). 

In  the  case  of  a  baby  five  or  six  months  of  age,  with  a  history  of 
vomiting  over  a  period  of  three  or  four  weeks,  the  age  alone  is  a  factor 
against  pyloric  stenosis.  In  exceedingly  rare  cases  seen  in  older  chil- 
dren vomiting  due  to  stenosis  might  be  confounded  with  cyclic  vomiting. 
Holt  has  seen  one  such  case. 

Sex. — No  great  stress  is  to  be  laid  on  sex  in  the  diagnosis  of  this 
disease.  The  large  number  of  male  patients,  however,  contrasts  re- 
markably with  the  corresponding  small  number  of  females.  Out  of  a 
collection  of  42  cases  in  which  this  point  was  noted,  35  were  males 
(Still).  According  to  Ibrahim,  males  are  affected  about  four  times  as 
often  as  females.  Cases  have  been  met  with  in  the  same  family  (Fre- 
und) .     This  occurred  once  under  my  own  observation.     Some  authori- 


PYLORIC    STENOSIS  187 

ties  state  that  when  the  disease  occurs  in  girl  babies,  it  is  usually  of  a 
mild  form. 

Etiology. — Pyloric  stenosis  is  one  of  the  diseases  concerning  which  a 
great  amount  of  theorizing  has  been  done,  especially  in  the  early  days, 
when  few  autopsy  specimens  were  at  hand.  Most  of  the  various  sur- 
mises have  been  discarded,  such  as  the  probability  of  the  stomach 
undergoing  an  agonal  contraction,  thus  producing  the  thickening 
(Pfaundler).  Many  new  views,  however,  have  been  offered,  as  the 
various  names  of  the  disease  might  suggest.  Prominent,  and  among 
the  most  universally  recognized,  theories  up  to  1897  were  those  of 
Hirschsprung  and  John  Thomson.  According  to  the  former,  the  dis- 
ease was  due  to  a  congenital  organic  defect,  resulting  from  a  primary 
pathologic  hypertrophy  of  the  pyloric  wall,  which  constricted  the 
lumen,  Thomson  contended  that  the  essential  lesion  was  not  muscular, 
but  primarily  nervous:  "A  functional  disorder  of  the  nerves  of  the 
stomach  and  pylorus  leading  to  ill-co5rdinated  and  therefore  antago- 
nistic action  of  their  muscular  arrangements."  This  latter  view  corre- 
sponds very  closely  to  Still's  theory  of  "stomach  stuttering." 

There  is,  to  date,  no  convincing  evidence  that  the  spasm  is  set  up 
by  erroneous  feeding  or  by  hyperacidity.  In  7  of  11  cases  Feer  found 
the  total  acidity  varying  from  50  to  105,  and  free  hydrochloric  acid  from 
0  to  50.  Similar  results  have  been  obtained  by  other  observers  (Ram- 
sey, Bernheim,  Karo,  Engel,  Freund,  Miller,  Clark).  Miller  and  Will- 
cox  (1901),  in  a  series  of  carefully  conducted  investigations,  attempted 
to  show  that  pylorospasm  may  be  due  to  hyperacidity,  and  that  in 
hypertrophic  stenosis,  spasm,  if  present,  is  produced  by  some  other 
cause.     In  hypertrophic  stenosis  hyperacidity  is  very  common. 

Of  recent  years  most  authorities  have  regarded  the  condition  as 
primarily  spasmodic,  and  probably  due  to  gastric  or  duodenal  irritation 
or  nervous  disturbances.  According  to  this  theory,  the  hypertrophy 
is  secondary  and  depends  to  a  large  extent  upon  the  degree  of  spasm. 
The  possible  existence  of  a  certain  amount  of  antenatal  hypertrophy 
may  be  appreciated  when  one  considers  that  the  pylorus  begins  to 
form  as  early  as  the  third  month  of  fetal  life.  Such  hyperplasia  has 
actually  been  found  by  C.  T.  Dent  in  a  seven  months'  fetus.  Pyloro- 
spasm has  its  analogue  in  certain  other  spasmodic  conditions  of  the 
circular  fibers,  such  as  constipation  due  to  a  spastic  condition  of  the 
sphincter  ani,  and  various  allied  conditions  of  the  larynx  and  bronchi. 
By  some  observers,  however,  the  essential  condition  in  pyloric  steno- 
sis is  regarded  as  a  primary  hypertrophy  with  secondary  spasm. 

Pathology. — The  findings  at  postmortem  are  remarkably  uniform. 
The  alimentary  canal  below  the  pylorus  is  perfectly  normal.  The 
esophagus  is  sometimes  noticeably  dilated,  sometimes  of  normal 
caliber. 

The  stomach  is  usually  much  dilated,  the  lower  border  being  fre- 
quently below  the  umbilicus;  the  wall  at  the  cardiac  end  is  as  thin  as 
normal,  but  elsewhere  much  thicker,  especially  toward  the  pj'lorus. 
Occasionally  the  cardia  may  assist  in  the  general  hypertrophy.     The 


188  THE    PRACTICE    OF    PEDIATRICS 

pyloric  part  of  the  stomach  consists  of  a  rigid,  resistant,  cartilaginous 
mass  of  a  bulging  or  nearly  cylindric  shape.  The  swelling  appears 
like  a  separatelj^  interpolated  insertion  between  the  stomach  and  duo- 
denum. When  looked  at  from  the  duodenum,  the  pylorus  seems  al- 
most closed,  the  mucous  membrane  being  puckered  by  the  contraction 
of  the  hypertrophied  muscular  wall,  not  unlike  that  of  the  os  uteri.  No 
fibrous  stricture  is  present,  and  the  whole  narrowing  seems  to  be  due  to 
compression  by  hypertrophied  muscle.  The  tumor  enlargement  varies 
from  2  to  3  cm.  in  length,  and  from  13-^  to  2  cm.  in  thickness.  On 
section,  the  thickening  appears  to  be  due  to  the  hypertrophy  of  the 
circular  fibers,  which  may  be  two  or  three  times  their  normal  thickness. 
Finkelstein  reports  a  case  in  which  the  thickening  was  due  to  an  in- 
crease in  the  longitudinal  fibers.  The  lumen  varies  in  size.  In  some 
instances  it  barely  admits  a  fine  probe.  Walbach,  in  one  case,  found 
the  lumen  2  cm.  in  diameter.  Occasionally  a  slight  connective-tissue 
increase  is  found  in  addition  to  a  slight  thickening  of  the  mucosa  and 
submucosa.  Catarrhal  or  inflammatory  changes  are  usually  absent. 
The  test  of  functional  potency  by  hydrostatic  pressure  is  fallacious,  for 
the  redundant  folds  of  mucous  membrane  may  act  as  valves. 

Symptoms. — Vomiting  is  the  only  active  symptom  of  the  stenosis, 
whether  it  is  spasmodic  or  due  to  stricture.  The  history  is  usually  that 
of  an  infant,  apparently  normal  at  birth,  who  remains  well  for  two  or 
three  weeks  or  more.  The  child  regains  the  early  loss  in  weight,  the 
stools  are  normal,  and  there  is  no  suggestion  of  gastric  disturbance. 
Then,  without  apparent  cause,  the  child,  whether  breast  or  bottle  fed, 
begins  to  reject  the  food.  I  have  never  known  the  vomiting  to  occur 
before  the  second  week,  except  in  spasmodic  cases,  in  which  vomiting 
may  occur  at  birth,  or  perhaps  not  until  after  the  eighth  week. 

Vomiting. — The  vomiting  may  occur  after  each  feeding.  More 
frequently  two  or  three  nursings  are  retained  and  then  a  large  amount 
is  ejected,  so  that  the  nurse  or  mother  is  impressed  with  the  large 
amount  of  vomiting,  and  volunteers  the  information  that  two  or  three 
feedings  would  be  necessary  to  supply  the  large  amount  of  food  lost. 
In  most  cases  the  vomiting  is  forcible  and  decidedly  explosive  in 
character. 

Retention. — The  stomach  of  an  infant  who  takes  from  three  to  four 
ounces  at  a  feeding  should  be  empty  at  the  end  of  three  hours.  When 
food  is  retained  longer  than  three  hours  it  means,  in  a  vast  majority  of 
the  cases,  an  obstruction  at  the  pyloric  outlet  and  is  a  very  valuable 
sign  in  pyloric  stenosis.  A  retention  of  one  or  two  ounces  is  not  at 
all  unusual  and  when  there  is  an  associated  dilatation  of  the  stomach — 
two  or  more  feedings  being  retained — the  retention  has  been  four  to 
five  ounces.  A  convenient  device  for  testing  the  retention  is  the  Hess 
bulb  (Fig.  17).  By  this  device  all  the  contained  fluid  in  the  stomach 
may  be  aspirated  into  the  glass  bulb  and  measured. 

Constipation. — With  the  vomiting  is  associated  constipation.  The 
passages,  previously  full  and  normal,  become  very  scanty,  and  are 
passed  only  upon  rectal  stimulation.     Mucus  is  usually  mixed  with  the 


PYLORIC    STENOSIS 


189 


feces.  The  degree  of  constipation  depends  upon  the  degree  of  per- 
manency of  the  stricture.  In  the  purely  spasmodic  cases  considerable 
fecal  material  will  be  passed.  A  lesser  amount  will  be  passed  in  cases 
of  the  combined  type. 

Loss  in  Weight. — There  is  rapid  loss  in  weight,  as  would  be  expected. 
I  have  repeatedly  seen  such  infants  reduced  to  mere  skeletons. 

Appetite. — These  patients  are  voraciously  hungry,  and  will  take 
everything  in  the  form  of  liquid  food  that  is  offered.  Water  will 
frequently  be  taken,  as  well  as  milk  mixtures  or  the  breast. 

Absence  of  Other  Signs  of  Illness. — There  is  no  elevation  of  the  tem- 
perature and  there  are  no  nervous  phenomena.     The  urine  is  scanty 


17.— The  Hess  bulb. 


and  of  high  specific  gravity,  but  shows  no  evidence  of  diseased  kidneys. 
The  child  appears  ill  only  on  account  of  the  wasting  and  moderate 
prostration. 

Diagnosis. — In  all  young  infants  who  develop  persistent  vomiting 
with  constipation,  or  even  persistent  vomiting  without  constipation, 
the  possibility  of  stenosis  of  the  pylorus  should  be  considered. 

The  Peristaltic  Wave. — This  sign  consists  of  a  rounded,  circum- 
scribed elevation  of  the  abdominal  wall,  a  lump  from  one  to  two  inches 
in  diameter,  which  forms  at  the  left  of  the  median  line,  sometimes  ap- 
pearing to  rise  from  the  margin  of  the  ribs,  and  passes  across  the 
epigastrium    (maintaining   its   original    size  in  transit)  to  the  right 


190 


THE    PRACTICE    OF    PEDIATRICS 


hypochondrium,  where  it  disappears.  In  a  few  seconds  the  phe- 
nomenon is  repeated.  Not  infrequently,  before  the  first  wave  disap- 
pears a  second  will  form.  I  have  seen  cases  in  which  the  elevation 
and  depression  (see  Fig.  18)  were  sufficient  to  involve  the  entire  ab- 
dominal wall.  The  peristaltic  wave  described  occurs  in  no  other 
condition. 

Method  of  Obtaining  the  Wave. — The  wave  may  best  be  demon- 
strated after  feeding.  The  stomach  should  not  be  overfull.  If  the 
usual  feeding  time  is  near,  two  ounces  of  food  or  wateF  are  given.  If 
the  child  has  been  recently  fed,  before  giving  the  food  the  stomach  is 
washed  out.  The  abdomen  is  then  exposed,  and  usually  before  the 
child  has  finished  the  bottle  the  peristalsis  will  appear.  Occasionally 
a  case  is  seen  in  which  no  peristalsis  will  be  elicited  at  the  first 
examination. 


Fig.   IS. — Pyloric  stenosis. 

The  Tumor. — Palpation  of  the  tumor  through  the  abdominal  wall 
is  possible  in  nearly  all  cases.  Considerable  practice  is  required  in 
order  to  be  able  to  locate  the  tumor.  I  have  not  been  as  successful  as 
other  writers  in  demonstrating  this  conclusive  sign.  Still  was  able 
to  palpate  the  pyloric  tumor  in  41  out  of  42  cases. 

Palpation  is  aided  by  a  partially  filled  stomach  that  is  in  active 
peristalsis. 

Differential  Diagnosis  Between  Hypertrophic  Stenosis  and  Pyloric 
Spasm  and  Obstruction  of  the  Combined  Type. — The  palpable  pylorus 
may  be  looked  upon  as  a  hypertrophic  pylorus.  In  a  pylorus,  moreover, 
that  has  undergone  sufficient  thickening  to  be  palpable  the  connective- 
tissue  changes  are  in  all  probability  sufficient  to  necessitate  operation. 
Constipation  is  always  present  in  stenosis  of  the  hypertrophic  form. 
There  is  dilatation  of  the  stomach,  and  the  vomiting  is  persistent.     In 


PYLORIC    STENOSIS  191 

the  spasmodic  type  the  vomiting  appears  to  occur  periodically — per- 
haps not  oftener  than  once  or  twice  a  day.  In  some  cases  of  simple 
spasm  there  will  be  no  vomiting  for  a  day  or  two,  and  during  this  time 
the  stools  will  be  fairly  large.  The  short  cessation  will  then  be  fol- 
lowed by  a  return  of  the  repeated  emesis.  Cases  of  this  type  present 
the  best  chances  for  cure  without  operation. 

In  the  combined  type,  in  which  there  is  moderate  hypertrophy  and 
spasm,  the  stenosis,  when  the  stomach  is  at  rest,  is  moderate  in  degree. 
It  is  possible  for  a  considerable  portion  of  the  stomach-contents  to  pass 
into  the  intestine  if  but  small  quantities  of  food  are  given  at  one  time. 
A  private  case  which  I  expected  would  recover  without  operation  rep- 
resented this  type.  Vomiting  occurred  sometimes  once  a  day^ — never 
more  than  twice.  The  active  peristaltic  wave  was  present.  The  stools 
were  fairly  large  and  well  digested,  from  10  to  15  ounces  of  food  being 
retained  daily.  Without  apparent  cause,  the  child  went  into  collapse 
and  died.  The  autopsy  showed  a  pyloric  canal  about  3^6  inch  in 
diameter,  and  revealed  moderate  thickening  and  hypertrophy  of  the 
circular  fibers. 

Alfred  F.  Hess,*  of  New  York,  finds  the  catheter  (No.  15  F.)  of 
much  use  in  the  diagnosis  of  pyloric  stenosis.  Under  normal  conditions 
the  catheter  readily  passes  through  the  pylorus,  and  bile  can  be  aspir- 
ated. If  there  is  stenosis,  the  catheter  will  not  pass  the  pylorus.  In 
cases  of  simple  vomiting  which  may  simulate  stenosis  the  ready  passage 
of  the  catheter  proves  the  absence  of  stenosis.  That  there  may  be 
pyloric  spasm  without  hypertrophy,  producing  typical  signs  of  the 
disease — is  represented  in  a  private  patient  which  began  vomiting  at 
three  weeks.  There  was  the  peristaltic  wave,  vomiting  several  times  a 
day,  emaciation  and  constipation.  The  child  was  seen  by  a  surgeon 
and  operation  partially  arranged  for.  The  child  was  bottle-fed  and  pre- 
paratory to  the  operation  a  wet-nurse  was  solicited  in  order  that  the 
post-operative  management  might  be  the  more  secure.  The  wet-nurse 
was  supplied  and  the  baby's  stomach  was  washed  daily.  In  four 
weeks  the  vomiting  had  subsided  and  the  child  gained  two  pounds 
two  ounces  in  weight.  There  was  no  further  trouble  with  the  case. 
Here  surely  was  not  a  case  of  organic  stenosis. 

Prognosis. — The  prognosis  is  dependent  upon  many  factors.  The 
age  of  the  patient  and  the  severe  nature  of  the  surgical  treatment 
are  such  that  operative  procedure  will  always  show  a  considerable 
mortality. 

The  severity  of  the  operation  and  the  tender  age  of  the  subject  are 
not  the  only  reasons  for  the  high  mortality.  Many  of  the  patients 
when  they  come  to  the  surgeon  are  so  emaciated  and  reduced  in  vitality 
that  operation  simply  hastens  the  end. 

In  surgical  cases  in  children  the  sm-geon  should  receive  the  con- 
sideration of  counsel  as  to  when  and  how  long  a  condition  may  continue 
and  still  afford  a  good  surgical  risk. 

Cases  with  Palpable  Tumor. — These  infants  should  be  given  the 
*  Amer.  Jour.  Dis.  of  Children,  vol.  iii,  p.  133. 


192  THE    PRACTICE    OF    PEDIATRICS 

advantage  of  immediate  operation.  Of  this  there  is  not  the  sHghtest 
doubt.  It  is  difficult  for  me  to  understand  how  physicians  who  have 
examined  postmortem  the  thick,  cartilaginous  pyloric  tissue,  with  its 
pin-hole  lumen,  can  advise  means  other  than  operation. 

The  Spasmodic  Cases. — There  are  probably  comparatively  few 
pyloric  cases  without  involvement  of  the  muscle  structure.  In  such 
cases  the  prognosis  is  good,  and  all  should  survive  without  operation. 

I7i  the  combined  cases  of  spas77i  and  hypertrophy,  which  represent  the 
largest  number  of  cases,  the  prognosis  is  dependent  largely  upon  the 
degree  of  hypertrophy  and  the  management.  Exclusive  of  operation, 
the  management  of  the  spasmodic  and  combined  type  is  the  same. 

Management. — Surgical. — The  great  majority  of  cases  come  to 
operation.  In  view  of  the  fact  that  the  presence  of  the  tumor  is  diffi- 
cult to  demonstrate,  it  is  not  wise  for  the  physician  to  depend  on  this 
sign.  Frank  clinical  signs  and  symptoms  in  95  per  cent,  of  the  cases 
mean  that  an  organic  obstruction  exists  and  that  an  operation  will 
eventually  be  required.  It  is  best  to  operate  while  the  child  possesses 
a  good  resistance.  The  Rammstedt  operation  offers  the  best  in  results. 
This  operation  consists  in  making  a  longitudinal  incision  from  2  to  3 
cm.  in  length  through  the  serosa  and  the  hypertrophied  circular  mus- 
cle fibers  of  the  pylorus  down  to  the  thickened  mucosa.  The  duration 
of  the  operation,  according  to  Downes,  is  ten  to  twenty  minutes. 
Among  thirty-five  cases  operated  by  this  surgeon  by  pyloroplasty 
there  was  a  mortality  of  23  per  cent. 

Postoperative  Treatment. — Vomiting  after  operation  rarely  causes 
trouble.  Regurgitation,  which  is  troublesome,  will  occur  in  some 
patients.  This  may  be  obviated  by  bringing  the  force  of  gravity  into 
use  by  elevating  the  head  and  shoulders  of  the  patient  on  a  high 
pillow.  These  children  need  fluid  badly,  and  this  may  be  supplied, 
during  the  first  hours  after  the  operation,  by  the  "Murphy  drip." 

Food  may  be  given  two  hours  after  the  operation.  Two  to  three 
drams  of  breast  milk  may  be  given  every  two  to  three  hours.  The 
quantity  is  gradually  increased  so  that  the  child  is  getting  from  one- 
half  to  two  ounces  every  three  hours  at  the  end  of  the  third  day.  If 
breast  milk  is  not  obtainable,  fresh  cow's  milk  or  condensed  milk, 
suitably  diluted,  may  be  used. 

Palliative  measures  in  the  non-operative  types: 

First:  Diet — breast  milk  from  mother  or  wet-nurse.  If  breast  milk 
is  not  available,  suitably  modified  cow's  milk  given  in  weak  dilution  at 
first,  and  in  small  amounts,  one  teaspoonful  every  half-hour. 

Second:  Later  the  amount  of  nourishment  and  the  feeding  means 
must  be  determined  in  each  case.  If  breast  milk  feeding  is  not  possible, 
then  a  mixture  of  cow's  milk,  low  in  fat  and  sugar,  or  unsweetened 
condensed  milk,  may  be  given. 

Third:  The  stomach  should  be  washed  daily  with  5  per  cent,  bicar- 
bonate of  soda  solution. 

My  best  results  have  been  obtained  with  fat-free  plain  milk  or 
evaporated  (unsweetened  condensed)  milk.     The  milk  is  diluted  with  a 


ACUTE    GASTRO-ENTERIC    INTOXICATION  193 

gruel,  which  adds  to  the  carbohydrate  content.  In  any  case  of  pyloric 
obstruction  the  passage  of  fluids  from  the  stomach  is  delayed.  The 
presence  of  fat  and  sugar  gives  rise  to  irritating  chemical  changes  in  the 
contents  of  an  organ  already  inclined  to  eject  its  contents. 

Catheter  Feeding. — Feeding  by  means  of  the  catheter  No.  15  (French) 
passed  into  the  duodenum  has  been  a  useful  means,  according  to 
Hess,  of  supplying  nourishment  to  persistent  vomiting  cases. 

Medication. — I  am  further  verj^  much  inclined  to  keep  out  of  the 
stomach  everything  except  food  and  a  weak  bicarbonate  of  soda  so- 
lution. Bicarbonate  of  soda,  10  to  20  grains  to  the  pint,  is  invariably 
added  to  either  the  food  or  the  water.  I  do  not  look  with  favor  upon 
the  preparations  of  opium  or  the  bromids,  and  think  that  little  is  to 
be  expected  from  them.  In  some  cases  they  increase  the  vomiting. 
If  a  sedative  is  to  be  administered  by  the  stomach,  paregoric,  5  to  10 
drops,  well  diluted,  answers  best. 

Later  Operations. — When  the  vomiting  continues  in  spite  of  treat- 
ment, and  the  child  shows  progressive  loss  in  weight  and  strength,  it  is 
safe  to  assume  that  a  considerable  degree  of  hypertrophic  stenosis  exists 
and  operation  should  not  be  delayed.  Temporizing  is  safe  only  when 
there  is  no  pronounced  loss  in  weight. 

Rectal  Medication. — For  sedative  effects  six  grains  of  bromid  of 
sodium  with  one  grain  of  chloral  in  one  ounce  of  mucilage  of  acacia  may 
be  passed  into  the  descending  colon  through  a  No.  14  American  cathe- 
ter. In  order  to  place  the  solution  in  the  colon,  the  catheter  should  be 
introduced  eight  inches.  The  colonic  medication  will  be  useful  for  a 
day  or  two  only,  as  the  parts  soon  become  intolerant,  and  such  medi- 
cation is  no  longer  retained.  I  never  employ  this  method  oftener 
than  twice  in  twenty-four  hours. 

Local  Applications  to  the  Stomach. — ^Local  treatment  is  of  little  or  no 
value.  I  have  yet  to  see  any  improvement  follow  the  use  of  stupes, 
compresses,  or  irritant  applications. 

ACUTE  GASTRO-ENTERIC  INTOXICATION 

In  the  consideration  of  this  subject  we  deal  with  a  most  important 
portion  of  the  child's  anatomy,  parts  that  differ  in  their  location  in  the 
body,  in  their  anatomic  structure,  and  in  function.  The  gastro-intes- 
tinal  tract  is  exposed,  of  necessity,  to  influences  from  without  which 
may  exert  decided  effects  upon  the  physiologic  processes  of  its  different 
parts.  It  is  obvious  that  there  may  be  lesions  in  any  part  of  its  struc- 
ture, and  that  such  lesions  may  cause  a  derangement  of  function,  if  not 
actual  disease,  by  transference  (bacterial)  to  other  parts  of  the  tract. 
Thus  there  may  be  lesions,  single  or  multiple,  in  various  portions  of  the 
gastro-intestinal  tract.  There  may  be  a  simple  gastritis,  or  an  ileitis 
or  colitis  singly  or  in  combination,  entirely  independent  of  pathologic 
conditions  of  the  other  portions  of  the  tract.  The  function  of  the  gas- 
tro-intestinal tract  is  the  preparation  of  food-substances  for  the  use  of 
the  organism.  These  food-substances  are  perishable  in  character  and 
13 


194  THE    PRACTICE    OF    PEDIATRICS 

susceptible  to  bacterial  influences  and  chemical  change.  Obviously, 
this  long  tube,  adapted  for  absorption  and  of  an  anatomic  and  physio- 
logic construction  of  most  intricate  and  sensitive  nature,  offers  ready 
fields  for  bacterial  invasion  and  chemical  change,  and  consequently  is 
subjected  to  constant  insult  by  toxic  agents  resulting  from  bacterial 
and  chemical  processes. 

For  the  past  two  hundred  years  investigators  have  attempted  a 
classification  of  the  acute  gastro-intestinal  disorders,  and  while  much 
progress  has  been  made  in  framing  a  classification  sufficient  for  bedside 
and  teaching  purposes,  let  no  one  imagine  that  the  last  word  has  been 
said.  With  an  increase  in  knowledge  of  the  subject,  old  theories  and 
concepts  will  be  disproved  and  new  ones  evolved  which  may  share  the 
fate  of  their  predecessors.  It  is  not  wise  to  be  carried  away  by  the 
theories  of  our  time  concerning  a  subject  the  etiology  of  which  is  based 
upon  so  many  factors,  not  the  least  important  of  which  is  that  of 
physiological  chemistry,  a  subject  of  which  we  can  boast  but  little  abso- 
lute knowledge. 

Until  we  possess  demonstrable  facts,  it  is  best,  in  teaching,  not  to  go 
into  vague  chemical  and  metabolic  theories  which  no  one  under- 
stands. 

Types. — The  gastro-intestinal  disorders,  exclusive  of  the  simple 
digestive  derangements  already  mentioned,  may  be  divided  clinically 
into  two  types;  first,  those  in  which  there  is  an  acute,  severe,  gastro- 
enteric intoxication  without  demonstrable  lesions  and  with  characteris- 
tic symptoms;  second,  acute  ileocolitis  with  moderate  early  intoxica- 
tion, characteristic  symptoms,  and  demonstrable  lesions.  Clinically, 
and  probably  etiologically,  there  are  two  forms  of  acute  gastro-enteric 
intoxication. 

A.  Cholera  infantum. 

B.  Acute  enteric  intoxication. 

While  there  are  various  degrees  of  severity  of  the  acute  gastro- 
enteric disorders,  certain  features  are  common  to  all: 

(a)  They  are  most  prevalent  during  the  hot  months. 

(b)  Selection  as  to  the  type  of  child  attacked.  The  rachitic  and 
those  suffering  from  various  forms  of  malnutrition  are  the  most  sus- 
ceptible subjects. 

(c)  Nearly  all  the  patients  are  bottle-fed. 

(d)  The  illness  is  rarely  primary.  A  field  has  been  prepared  for 
the  toxic  process  by  mild,  but  perhaps  persistent,  digestive  derange- 
ments. 

Gastroenteric  Intoxication 

This  form  of  intoxication,  while  acute  in  character,  is  rarely  of  pri- 
mary origin.  It  is  usually  preceded  by  disordered  gastro-enteric 
digestion. 

The  onset  is  sudden,  with  pronounced  prostration,  persistent  vomit- 
ing, retching,  and  the  passage  of  large,  watery  stools  of  greenish  color. 
The  pulse  is  soft  and  rapid. 


ACUTE    GASTRO-ENTERIC    INTOXICATION  195 

In  a  few  hours  the  prostration  becomes  extreme,  the  respiration 
quick  and  shallow,  the  eyes  sunken,  and  the  skin  dry  and  ashen  in  color. 
The  extremities  are  cold;  thirst  is  intense.  The  fontanel  is  depressed. 
The  anus  becomes  relaxed,  and  often  there  is  a  constant  slight  discharge 
of  the  intestinal  contents. 

The  temperature  is  variable  and  inconstant — it  may  be  high,  105°F. 
to  106°F.,  or  it  may  never  arise  above  the  normal.  The  lower  tem- 
perature cases  with  repeated  vomiting  and  profuse  diarrhea  are  the 
most  hopeless.  The  system  is  so  overwhelmed  by  the  poisoning  that 
a  reaction  is  impossible. 

As  the  disease  progresses  toward  a  fatal  termination  the  patient 
develops  stupor  and  occasionally  convulsions.  Coma  rapidly  ensues, 
and  death  from  a  virulent  poisoning  process  is  the  outcome. 

I  have  seen  infants  cHe  in  twelve  hours  from  the  onset  of  the  symp- 
toms. The  loss  of  weight  is  most  rapid.  In  twenty  hours  a  nine- 
months-old  baby  lost  two  pounds.  The  loss  of  a  pound  or  more  in 
twenty-four  hours  is  not  at  all  unusual.  At  the  Nursery  and  Child's 
Hospital  a  child  fifteen  months  of  age  was  taken  acutely  ill  with  vomit- 
ing and  diarrhea  at  11  o'clock  in  the  morning.  The  child  was  seen  by 
the  House  Physician,  and  suitable  management  was  instituted.  On 
my  rounds  at  4  o'clock  we  discovered  the  child  moribund  in  spite  of 
active  treatment,  and  death  took  place  six  hours  later.  Thirty-one 
children  in  this  institution  were  poisoned  by  a  can  of  stale  milk  left  by 
a  dealer  who  was  short  of  a  sufficient  fresh  supply.  Thirteen  deaths 
in  children  under  eighteen  months  were  traceable  to  this  can  of  milk. 

Not  all  cases  are  as  severe  as  the  foregoing  descriptions  represent. 
There  are  cases  in  which  there  is  a  sharp  rise  in  temperature, — 105°  to 
106°F., — with  active  vomiting  and  profuse  watery  stools.  The  fever 
soon  subsides.  The  stomach  is  washed,  milk  is  withheld,  boiled  water, 
weak  barley-water,  or  rice-water  No.  1  (see  formula,  p.  70)  is  given, 
and  the  child  is  well  in  a  few  days.  In  the  more  severe  cases  that  re- 
cover several  weeks  elapse  before  the  child  regains  his  usual  vigor. 

The  Urine. — The  urine  contains  albumin,  and  usually  a  few  hyaline 
and  epithelial  casts — findings  that  are  common  in  all  severe  acute  toxic 
processes,  and  have  no  immediate  or  remote  bearing  upon  the  illness. 
While  I  was  resident  physican  at  the  N.  Y.  Infant  Asylum  in  1890,  the 
examination  of  the  urine  in  a  series  of  12  cases  of  acute  gastro-intestinal 
intoxication  showed  the  presence  of  lactose. 

Acidosis. — Infants  ill  with  intestinal  intoxication  not  infrequently 
develop  a  severe  acidosis.  In  such  cases  the  prostration  is  extreme. 
There  is  rapid  breathing — evidence  of  air-hunger  without  cyanosis  or 
respiratory  obstruction,  and  with  the  chest  signs  negative.  Coma 
early  supervenes  and  the  outcome  is  usually  fatal. 

Pathology. — The  postmortem  findings  are  negligible.  The  stom- 
ach and  intestines  present  a  very  pale,  washed-out  appearance.  The 
intestine  usually  contains  a  mucoid,  yellowish  substance  entirely  free 
from  fecal  odor.  The  brain  may  show  a  cerebral  anemia;  more  often 
there  is  moderate  edema  of  the  meninges — the  so-called  wet-brain. 


196  THE    PRACTICE    OF    PEDIATRICS 

Treatment. — The  management  of  the  case  depends  entirely  upon 
the  natm-e  and  urgency  of  the  symptoms.  In  the  acute  choleraic 
cases,  with  repeated  vomiting,  severe  toxemia,  retching,  and  profuse 
watery  stools,  stomach-washing  and  bowel  irrigations  are  useless  pro- 
cedures. We  must  support  the  patient  and  aid  him  to  bear  the  poison 
with  which  he  has  to  contend.  If  the  temperature  is  high  and  the 
skin  dry  and  hot,  a  cool  pack  to  the  trunk,  at  85°  to  90°F.,  subsequently 
moistened  with  water  at  this  temperature  every  half-hour,  will  often 
control  the  pyrexia.  If  the  feet  are  cold,  hot-water  bottles  should  be 
brought  into  use.  If  the  temperature  is  below  normal  and  the  periph- 
eral circulation  poor,  as  indicated  by  a  leaden  hue  of  the  skin,  a  hot- 
water  bath  at  108°F.  for  five  minutes  will  always  be  of  service.  The 
bath  may  be  repeated  at  half-hour  intervals.  In  addition,  the  imme- 
diate treatment  calls  for  hypodermic  stimulation  and  sedatives.  The 
administration  by  mouth  of  food  or  stimulants  should  not  be  attempted. 
Tincture  of  strophanthus  and  brandy,  hypodermatically,  have  served 
me  well  in  these  cases.  Twenty  drops  of  brandy  with  one  drop  of 
the  tincture  of  strophanthus  may  be  given  at  intervals  of  one,  two, 
three,  or  four  hours,  depending  upon  the  urgency  of  the  case.  A  com- 
bination of  morphin  and  atropin  may  be  used  in  cases  with  persistent 
vomiting,  with  a  view  to  controlling  the  attempts  at  vomiting  which 
exhaust  the  patient,  and  also  to  diminish  the  continuous  loss  of  the 
fluids  of  the  body,  from  the  repeated  large,  watery  stools.  Obviously, 
morphin  should  not  be  given  unless  this  condition  exists.  For  a  child 
one  year  of  age  }io  grain  of  morphin  may  be  given  with  }y-5oo  grain 
atropin,  and  repeated  as  required,  not  oftener  than  once  in  two  hours. 
After  the  first  year  }io  grain  of  morphin  may  be  given  as  an  initial 
dose.  Beneficial  effects  from  the  morphin  will  be  noted  in  a  diminution 
in  the  number  of  stools  and  the  frequency  of  the  vomiting.  In  milder 
cases  of  infection,  in  which  the  vomiting  and  defecation  are  less  fre- 
quent, a  different  course  is  to  be  pursued.  In  these  cases  there  should 
be  abstinence  from  food,  boiled  water  being  given  if  the  child  can  retain 
it.  If  vomiting  persists,  the  water  should  be  discontinued.  The 
stomach  should  be  washed  at  least  once  daily  and  the  colon  irrigated. 
If  the  irrigation  brings  away  mucus  and  fecal  matter,  it  should  be  re- 
peated at  intervals  of  from  eight  to  twelve  hours.  The  child  should 
never  be  disturbed  for  this  purpose  if  the  intestine  continues  to  empty 
itself  at  frequent  intervals.  A  reduction  in  the  temperature,  cessation 
of  the  vomiting,  and  a  diminution  in  the  number,  and  improvement  in 
the  character,  of  the  stools,  tell  us  whether  or  not  the  case  is  doing  well 
and  determine  the  further  treatment,  after  the  initial  dose  of  castor  oil 
or  calomel  has  been  given.  As  a  rule,  the  milder  type  of  case  does 
better  when  calomel  is  used.  If  there  is  a  tendency  to  vomit,  the  oil 
will  rarely  be  retained,  regardless  of  how  it  is  given.  From  3^^ 5  to 
3^0  grain  of  calomel  may  be  given  at  fifteen-minute  intervals  until  one 
grain  is  given.  While  slower  in  its  action,  it  is  ultimately  of  more  bene- 
fit than  the  oil,  which  is  rejected. 

Milk  Substitutes. — When  the  vomiting  has  subsided,   teaspoonful 


ACUTE    GASTRO-ENTERIC    INTOXICATION  197 

doses  of  plain  water,  bicarbonate  of  soda  solution,  barley-water, 
granum-water,  or  rice-water,  should  be  given  at  fifteen-minute  or  haK- 
hour  intervals,  and  the  amount  should  be  increased  in  quantity  and 
be  given  less  frequently  as  the  case  improves.  It  is  well,  in  using  milk 
substitutes,  such  as  cereal  waters,  to  use  alternately,  for  the  sake  of 
variety,  three  or  four  different  preparations.  The  child  will  not  so  soon 
tire  of  the  milk  substitute  as  when  but  one  is  given,  and  will  thus  take 
more  food.  It  is  extremely  rare  that  the  substitutes  barley,  rice,  or 
granum  will  not  be  taken  if  used  in  this  way,  particularly  if  they  are 
made  more  palatable  by  the  addition  of  salt  and  sugar  or  saccharin. 
In  cases  showing  signs  of  acidosis,  bicarbonate  of  soda  should  be  given 
at  once,  10  grains  every  hour  if  possible,  until  the  patient  receives  at 
least  120  grains  in  twenty-four  hours.  It  is  to  these  urgent  cases  that 
the  soda  should  be  given  intravenously  or  by  hypodermoclysis  (p.  796). 

Termination. — The  termination  of  acute  gastro-intestinal  intoxica- 
tion is  in  death,  prompt  recovery,  or  in  the  development  of  ileocolitis. 
The  transition  to  an  ileocolitis  in  some  cases  is  so  sudden  that  its  exist- 
ence from  the  onset  is  often  assumed.  That  such  is  not  the  case  is 
proved  by  a  large  autopsy  experience  in  hospital  and  institution  work, 
with  cases  dying  in  a  day  or  two  from  toxemia,  in  which  no  intestinal 
lesions  of  consequence  were  found.  The  continuation  of  faver  and 
diarrhea,  with  loose  green  mucous  stools,  means  that  an  ileocolitis  has 
developed  as  a  result  of  the  toxic  agents  in  the  intestine. 

Drugs. — Unusual  care  must  be  exercised  in  the  use  of  astringent 
drugs  in  the  cases  we  are  discussing.  I  refer  particularly  to  cases  that 
are  mild  or  moderately  severe.  It  is  to  be  remembered  that  it  is  in  the 
intestinal  contents  that  the  trouble  exists,  and  not  in  the  intestinal 
structure,  and  that  the  diarrhea  is  a  conservative  attempt  on  the  part 
of  nature  to  protect  the  intestinal  structure.  Our  first  efforts,  there- 
fore, should  not  be  directed  toward  stopping  the  diarrhea,  but  toward 
assisting  in  the  elimination  of  the  intestinal  contents  productive  of  the 
illness.  The  indiscriminate  use  of  opium  and  astringents  may  do  ir- 
reparable damage  in  a  very  short  time  through  a  locking  up  of  the  in- 
testine, which  may  be  followed  by  a  sudden  rise  in  temperature,  convul- 
sions, coma,  and  death.  Opium  is  a  most  useful  drug  for  the  treatment 
of  diarrhea  in  children,  but  must  be  used  with  caution.  When  there  is 
tenesmus,  with  frequent  large,  watery  stools,  opium  may  be  given  in 
small  doses  sufficient  to  control  the  number  and  character  of  the  stools, 
with  a  view  to  prevention  of  an  excessive  loss  of  fluids  from  the  bodj\ 
This  drug  should  never  be  given  when  there  are  only  four  or  five  free 
evacuations  in  twenty-four  hours,  associated  with  more  or  less  fever,  as 
in  these  cases  this  number  is  required  to  maintain  proper  drainage. 
The  opium  should  further  be  given  independently  of  other  medication, 
so  that  its  use  may  be  stopped  when  the  excessive  number  of  stools 
ceases,  or  in  the  event  of  a  rise  in  temperature  after  it  has  been  given. 
It  would  not  be  desirable,  perhaps,  to  discontinue  the  bismuth  or  other 
drugs  which  may  have  formed  a  part  of  the  prescription.  In  using 
opium  I  prefer  Dover's  powder,  }/i  to  3^^  grain,  at  intervals  of  two  or 


198  THE    PRACTICE    OF    PEDIATRICS 

three  hours,  for  a  child  from  six  to  eighteen  months  of  age.  Bismuth 
sub  nitrate  in  not  less  than  10-grain  doses  at  two-hour  intervals  has  given 
most  satisfactory  results.  In  order  to  be  of  service  it  must  produce 
black  stools.  In  other  words,  if  the  bismuth  is  not  converted  into  the 
sulphid  in  the  intestine,  it  apparentlj^  is  of  no  service;  if  it  passes 
through  the  bowel  unchanged,  no  favorable  influence  will  be  exerted  on 
the  intestinal  contents.  This  occurs  in  a  small  percentage  of  cases.  In 
such  an  event  the  necessary  amount  of  sulphur  may  be  supplied  by  the 
use  of  precipitated  sulphur,  one  grain  being  added  to  each  dose  of  the 
bismuth.  A  convenient  and  agreeable  way  of  giving  the  bismuth  is 
the  following: 

I^     Bismuthi  subnitratis 3v 

Syrupi  rhei  aromatic! 3"]' 

AquEB q.  s.  ad     5  iv 

M.  Sig. — One  teaspoonful  every  two  hours. 

If  sulphur  is  necessary,  a  one-grain  powder  may  be  added  to  each  dose  of 
the  bismuth  mixture  at  the  time  of  its  administration.  In  the  same 
way  Dover's  powder,  if  opium  is  indicated,  may  be  dropped  into  the 
bismuth  mixture.  The  bismuth  is  continued  in  the  large  doses  until 
the  child  is  ready  for  milk,  when  the  dose  is  diminished  one-half  and 
continued  until  full  milk-feeding  is  permissible,  or  until  constipation 
demands  its  discontinuance.  In  using  the  bismuth  in  the  large  doses 
advised  it  is  necessary  that  the  chemically  pure  drug  be  obtained. 
If  free  nitric  acid  or  arsenic  is  present,  as  is  the  case  in  some  of  the 
commercial  bismuth  on  the  market,  vomiting  may  result,  or  symptoms 
of  arsenical  poisoning  may  develop.  Irrigation  of  the  colon  (p.  793) 
may  be  used  when  there  is  a  tendency  to  bowel  inactivity  with  high 
temperature.  If  there  are  loose  watery  passages,  irrigation  is  not 
called  for. 

Hypodermoclysis. — The  injection  of  warm  normal  salt  solution  into 
the  cellular  structures  of  the  body  is  frequently  advocated  by  pediatric 
writers  for  the  very  urgent  cases  in  which  there  is  extreme  prostration 
and  rapid  loss  in  weight  due  to  the  persistent  watery  discharges.  I 
have  employed  this  treatment  in  a  great  many  cases  and  have  never 
demonstrated  that  it  is  a  measure  of  any  great  utility.  In  the  cases 
where  the  addition  of  the  fluid  is  most  needed,  it  will  not  be  absorbed 
because  of  the  lowered  vitality  of  the  patient.  Those  whose  tissues  are 
able  to  take  up  the  salt  solution  appear  to  do  well  without  it. 

Diet. — A  difficult  problem  of  no  little  importance  is  the  nutrition  of 
the  patient  after  the  acute  symptoms  have  subsided.  When  the  tem- 
perature has  been  normal  for  two  or  three  days,  and  the  character  of  the 
stools  improves  to  such  a  degree  that  freer  feeding  than  carbohydrate 
decoctions  is  to  be  thought  of,  unusual  care  is  necessary  in  order  to 
avoid  a  reinfection. 

Skimmed  Milk. — It  must,  of  course,  be  our  effort  to  resume  milk- 
feeding  as  early  as  possible,  but  in  resuming  milk  the  amount  given 
must  be  increased  very  gradually — at  first  only  one-quarter  to  one-half 
ounce  of  skimmed  milk  being  given  in  every  second  feeding  of  the  cereal 


ACUTE    GASTRO-ENTERIC    INTOXICATION  199 

gruel.  In  not  a  few  cases  even  these  small  amounts  will  result  in  a  rise 
of  temperature  and  a  return  of  the  diarrhea.  There  are  always  patho- 
genic bacteria  remaining  in  the  intestinal  tract  after  an  illness  of  this 
nature,  which,  under  the  influence  of  such  a  favorable  culture-medium 
as  milk,  take  on  renewed  activity.  The  whole  illness  may,  therefore, 
be  repeated,  perhaps  with  greater  severity  than  the  original  one,  if  the 
milk-feeding  is  persisted  in.  I  have  repeatedly  seen  in  consultation 
infants  who  were  having  what  was  called  a  relapse.  What  they  did 
have  was  a  reinfection,  with  all  the  symptoms  as  severe  as,  or  more 
severe  than,  those  of  the  first  infection,  because  of  a  lack  of  appreciation 
of  the  necessity  of  great  care  in  resuming  milk.  To  avoid  mistakes  in 
feeding  at  this  time,  as  well  as  early  in  the  disease,  all  directions  should 
be  carefully  written.  Nurses  and  mothers  who  think  the  physician 
is  overcautious  and  pity  the  hungry  child  are  very  apt  to  forget  oral 
instructions  and  give  more  milk  than  is  ordered.  If  the  small  amount 
of  milk  agrees,  it  may  gradually  be  increased  by  the  addition  of  one- 
half  ounce  to  each  feeding  every  two  or  three  days.  Rarely,  however, 
will  it  be  possible  or  wise  to  attempt  to  give,  for  the  remainder  of  the 
summer,  as  strong  a  food  as  was  taken  before  the  illness.  In  milk- 
feeding  at  this  time  superfat  must  not  be  used.  Either  full  milk  or 
skimmed  milk,  properly  diluted,  should  be  given.  If  there  is  a  ten- 
dency to  relaxation  of  the  bowels,  with  frequent  passages,  I  order  the 
use  of  skimmed  milk.  Whether  the  milk  shall  be  pasteurized,  sterilized, 
or  raw  depends  upon  the  conditions  referred  to  under  Pasteurization 
and  Sterilization  (p.  74). 

The  Wet-nurse. — Every  summer  I  have  infants  under  my  care  who, 
after  an  attack  of  diarrhea,  cannot  take  even  as  small  an  amount  of 
cow's  milk  as  one-half  ounce  in  each  feeding.  Not  a  few  of  the  maras- 
mic  out-patient  infants  belong  to  this  class.  After  a  sharp  intestinal 
infection,  if  the  child  shows  inability  to  take  a  nutritious  diet,  a  wet- 
nurse  may  be  secured  for  the  well-to-do,  but  the  wet-nurse's  milk  will 
not  always  agree,  as  I  have  repeatedly  found.  Children  who  have  been 
very  ill  with  any  of  the  severe  forms  of  acute  intestinal  disease  of  sum- 
mer have,  as  a  result,  a  very  weak  fat-capacity,  and  the  wet-nurse's 
milk,  which  perhaps  contains  3  or  4  per  cent,  of  fat,  produces  diarrhea 
sufficient  to  require  its  discontinuance.  When  employing  the  wet- 
nurse  in  such  cases  it  is  best  never  to  permit  the  child  to  have  the  full 
allowance  of  breast-milk  at  first.  To  a  child  from  three  to  six  months 
of  age,  for  example,  it  is  wise  to  give  two  or  three  ounces  of  barley-water 
or  a  5  per  cent,  milk-sugar  water  before  each  nursing,  so  that  the  pa- 
tient will  be  satisfied  with  two  or  three  ounces  of  the  breast-milk. 
When  cow's  milk  cannot  be  given  and  the  nurse's  milk  does  not  agree, 
or  where  for  any  reason  a  wet-nurse  is  not  possible,  we  are  called  upon 
to  furnish  other  means  of  nutrition,  and  this,  with  our  available  re- 
sources, will  not  be  of  a  very  high  order  for  infants  under  one  year  of 
age. 

Animal  Broths. — The  animal  broths  are  of  very  little  service.  They 
contain  but  little  nourishment  even  if  given  in  considerable  quantity. 


200  THE    PRACTICE    OF    PEDIATRICS 

They  produce  a  decided  laxative  effect  during  convalescence  from 
diarrhea.  They  are  of  value  only  in  small  quantities  of  an  ounce  or 
two  added  to  the  gruel  to  make  it  more  palatable. 

Cereal  Decoctions. — Strong  starch  foods  cannot  be  digested  in  suffi- 
cient amount  to  maintain  the  nutrition.  Dextrinizing  processes  are 
therefore  of  considerable  service.  The  starch  is  thus  converted  into 
maltose,  which  is  readily  assimilable.  With  this,  as  with  the  broth,  the 
relaxing  effect  af  the  food  on  the  intestine  may  be  felt,  frequent  bowel 
evacuations  being  a  possible  result.  The  dextrinized  gruels,  however, 
are  always  worthy  of  trial,  and  they  have  been  of  considerable  service 
in  many  cases  as  a  substitute  for  cow's  milk. 

Evaporated  Milk. — When  breast-milk  is  not  available,  canned  con- 
densed milk  usually  answers  better  than  any  other  means  of  nutrition, 
being  much  more  easy  of  digestion  than  fresh  cow's  milk.  The  con- 
densed milk  at  first  is  added  in  small  quantities  to  the  cereal  water  made 
from  barley,  rice,  or  granum.  No.  1  strength  being  employed.  (See 
formulary,  p.  70).  One-half  dram  may  be  added  to  every  second  feed- 
ing for  the  first  day,  and  on  the  following  day  this  amount  may  be 
added  to  every  feeding.  The  condensed  milk  usually  will  be  well  taken 
and  well  digested.  It  is  gradually  increased  until  two,  three,  or  four 
drams  are  added  to  each  feeding.  When  it  seems  desirable  to  use  more 
than  two  drams  at  each  feeding,  the  fresh  or  evaporated  milk,  if  ob- 
tainable, furnishes  an  increased  amount  of  proteid  and  fat  without  the 
excessive  percentage  of  sugar.  In  not  a  few  cases  the  combination  of 
condensed  milk  and  cereal  diluent  must  furnish  the  nourishment  for 
the  remainder  of  the  heated  term.  With  the  advent  of  cooler  weather, 
one  ounce  of  weak  raw  milk  with  the  cereal  diluent  may  be  substituted 
for  one  of  the  regular  feedings,  and  later  this  may  gradually  be  in- 
creased one-half  or  one  ounce  at  a  time  until  the  raw  milk  comprises 
one-third  of  the  food  mixture.  When  this  point  is  reached,  an  attempt 
may  be  made  to  replace  with  raw  milk  another  feeding  of  the  con- 
densed milk.  In  this  way,  by  carefully  watching  the  case,  a  gradual 
replacing  of  the  condensed  milk  by  fresh  raw  milk  feeding  may  success- 
fully be  brought  about  until  raw  milk  only  is  given. 

Feedings  After  the  First  Year. — After  the  first  year  similar  methods 
may  be  followed  if  necessary,  although  at  this  age  plain  milk  will  usually 
be  tolerated  earlier,  and  other  means  of  feeding  than  the  milk  may 
be  brought  into  use.  Zwieback,  bread-crusts,  and  scraped  beef — two 
or  three  teapoonfuls  a  day — will  often  be  taken  without  inconvenience 
when  milk  in  sufficient  amount  for  proper  nutrition  disagrees.  At  this 
age  the  gruels  also  may  be  made  stronger — No.  2  or  No.  3  (see  formu- 
lary, p.  70)  will  often  be  well  borne.  An  important  point  to  be  re- 
membered in  feeding  convalescents  from  an  acute  gastro-enteric  dis- 
order is  that  the  food  must  not  be  forced,  and  that  the  child  must  be 
fed  only  in  accordance  with  his  digestive  capacity.  This  can  best  be 
determined  by  watching  the  temperature  and  the  stools.  The  gruels 
as  substitute  foods,  whether  alone  or  combined  with  condensed  milk, 
may  be  given  in  quantities  equal  to  those  which  the  child  was  accus- 


ACUTE    GASTRO-ENTERIC    INTOXICATION  201 

tomed  to  take  in  health,  and  they  may  be  given  at  more  frequent  inter- 
vals, never,  however,  oftener  than  every  two  hours.  A  child  who  has 
been  fed  at  four-hour  intervals  may  take  the  substitute  at  three-hour 
intervals.  If  fed  at  three-hour  intervals,  he  may  receive  the  substitute 
at  two  or  two  and  one-half  hour  intervals.  When  constipation  follows 
a  sharp  attack  of  diarrhea,  an, enema  may  be  used  not  oftener  than 
once  in  twenty-four  hours.  The  patient  should  not  be  given  a  laxative 
unless  there  is  fever  for  several  days  after  the  acute  symptoms  have 
subsided. 

Eiweiss  Milch  (Proteid  Milk). — In  young  infants — under  nine 
months  or  thereabouts — the  Eiweiss  Milch  of  Finkelstein  (p.  65)  may 
sometimes  be  used  with  good  effect.  The  taste,  however,  is  not 
agreeable  to  older  children,  many  of  whom  refuse  it.  In  such  instances 
saccharin  may  be  used  for  sweetening  purposes.  At  first,  after  the 
acute  symptoms  have  subsided,  it  is  given  with  barley-water,  one  part 
of  the  milk  to  three  parts  of  barley-water.  This  may  be  rapidly  in- 
creased to  one-half  milk  and  one-half  barley.  It  is  not  wise  in  most 
instances  to  give  the  milk  stronger  than  this  dilution.  The  Eiweiss 
Milch  will  be  retained  and  digested  more  readily  than  cow's  milk,  may 
be  given  in  larger  daily  amounts,  and  is  a  valuable  means  of  sustaining 
the  child  for  a  few  days  or  a  week  until  cow's  milk  or  condensed  milk 
(p.  95)  may  be  tolerated. 

Acute  Enteric  Intoxication 

This  type  of  intoxication  differs  clinically  from  the  foregoing  in  that 
there  is  no  vomiting  and  rarely  fever.  Any  elevation  of  temperature 
occurring  is  usually  no  more  than  a  sharp  rise  to  105°  or  106°F.,  and 
is  of  very  temporary  duration.  In  the  great  majority  of  the  cases  there 
is  no  such  elevation,  and  more  often  during  the  entire  course  the  tem- 
perature is  subnormal. 

The  presence  of  moderate  fever  is  a  favorable  sign,  and  indicates 
a  more  favorable  prognosis.  The  clinical  picture  is  similar  to  that  of  a 
case  of  gastro-enteric  intoxication  in  that  the  prostration  is  extreme, 
the  extremities  are  cold,  the  eyes  sunken,  the  fontanel  depressed,  and 
the  features  drawn  and  pinched.  Convulsions  and  muscular  twitch- 
ings  are  often  present.  The  mental  condition  is  dulled,  and  the  child 
lies  in  a  semi-stupor,  offering  little  or  no  resistance  when  disturbed. 
Diarrhea  may  be  present,  or  there  may  be  constipation,  with  or  with- 
out tympanites.  In  some  of  these  patients  there  is  an  intestinal 
paralysis  sufficient  to  resist  all  attempts  at  an  evacuation.  I  have  seen 
such  patients  die  in  twenty-four  hours  from  the  onset  without  a  degree 
of  temperature  and  without  a  sign  of  diarrhea. 

If  an  evacuation  occurs,  it  is  usually  a  green,  mucous  stool,  which 
may  be  very  offensive,  although  this  is  not  always  the  case. 

The  milder  forms  are  characterized  by  an  elevation  of  the  tempera- 
ture and  varying  degrees  of  prostration. 

Pathology. — The  intestinal  lesions  in  these  cases  are  of  no  conse- 
quence.    There  is  perhaps  an  area  of  congestion  here  and  there  in  the 


202  THE    PRACTICE    OF    PEDIATRICS 

lower  ileum  or  colon,  with  enlargement  of  the  solitary  follicles  and 
epithelial  desquamation. 

Treatment. — As  mentioned  above,  there  may  be  moderate  diarrhea 
or  marked  bowel  inactivity.  In  both  conditions  castor  oil  in  doses  of 
never  less  than  two  drams  is  to  be  given.  This  is  followed  by  discon- 
tinuance of  the  milk,  whether  the  patient  is  bottle-fed  or  nursed.  As 
a  substitute,  barley-water,  rice-water,  or  granum-water  No.  1  (p.  70) 
may  be  given,  with  salt  and  cane-sugar  or  saccharin  added  for  flavoring 
purposes.  The  treatment  of  these  cases  is  facilitated  by  the  fact  that, 
owing  to  the  absence  of  vomiting,  the  food  is  usually  well  taken  through- 
out the  entire  illness,  the  patient  ordinarily  being  very  thirsty.  In  the 
event  of  excessive  diarrhea — a  rare  condition — the  iridications  for  medi- 
cation are  the  same  as  those  given  under  Acute  Gastro-enteric  Intoxi- 
cation (p.  193).  Castor  oil  or  bicarbonate  of  soda  (p.  197)  is  to  be  used 
instead  of  calomel  at  the  beginning  of  the  illness. 

Intestinal  infection  with  defective  bowel  action  (paralytic  ileus)  often 
gives  us  our  most  difficult  cases  and  requires  different  treatment.  In 
this  type  poisons  generated  in  the  intestinal  contents  or  elsewhere 
seem  to  be  of  such  a  nature  as  to  cause  a  partial  paralysis  of  the  small 
intestine,  so  that  often,  only  with  the  greatest  difficulty,  can  an  evacua- 
tion be  induced.  So  difficult  is  this,  in  fact,  that  the  possibility  of  an 
acute  peritonitis  or  an  intussusception  may  occur  to  the  physician.  It 
is  very  necessary  to  maintain  bowel  action  and  to  prevent  the  accumu- 
lation of  gas,  which,  by  distending  the  intestine,  increases  the  tendency 
to  constipation.  Several  cases  of  this  nature,  with  high  temperature, 
sluggish  bowel  action,  and  intense  prostration,  are  seen  by  me  every 
year. 

Illustrative  Cases. — A  case  in  point  is  that  of  a  female  infant  nine  months  of  age 
who  had  been  most  difficult  to  feed.  In  July  she  developed  a  sudden  high  fever  of 
105°F.  and  convulsions,  which  were  followed  by  muscle  twitchings,  head-rolling, 
and  marked  prostration.  The  temperature  was  uninfluenced  by  local  means, 
although  there  was  no  diarrhea  or  vomiting.  The  attending  physician,  anticipat- 
ing intestinal  infection,  gave  calomel  in  divided  doses  with  frequent  bowel  irriga- 
tion. Foul-smelling  fecal  material  came  away  with  the  irrigation,  but  the  tem- 
perature and  the  nervous  symptoms  persisted;  in  fact,  the  condition  became 
worse.  I  first  saw  the  child  when  she  had  been  ill  ten  or  twelve  hours,  and  directed 
that  one-half  ounce  of  castor  oil  and  a  high  irrigation  of  normal  salt  solution  at 
80°F.  be  given.  As  a  result  of  the  treatment  there  was  one  small  green 
movement  in  addition  to  what  came  away  with  the  irrigation,  which  was  con- 
siderable. The  patient  was  somewhat  relieved  and  the  nervous  symptoms 
measurably  subsided,  though  the  temperature  still  ranged  between  104°  and 
105°F.  As  a  result  of  the  calomel,  1}4  grains  of  which  had  been  given,  and  the 
half-ounce  of  oil,  a  free  diarrhea  was  expected.  It  did  not,  however,  occur.  I  then 
directed  that  one-half  ounce  of  castor  oil  be  given  daily  in  addition  to  the  irrigations 
every  eight  hours.  This  was  followed  by  a  slight  improvement  in  the  symptoms, 
but  five  days  of  the  treatment  were  required,  one-half  ounce  of  oil  and  one  grain  of 
calomel  being  given  daily,  with  abdominal  massage,  before  the  resulting  peristalsis 
was  sufficient  to  relieve  the  intestine  of  its  contents.  After  the  establishment  of 
free  bowel  action  the  child  recovered. 

A  similar  case  which  resulted  fatally  was  seen  in  consultation.  In  this  patient, 
a  girl  eight  years  old,  the  toxemia  was  intense.  There  appeared  to  be  almost  com- 
plete paralysis  of  the  small  intestine.  Only  small,  very  foul  evacuations  could  be 
induced,  in  spite  of  the  most  active  local  and  internal  measures.  The  child  died 
from  toxemia  before  free  bowel  action  could  be  established. 

The  management  of  these  cases  of  the  inactive  type  is  partially 


ACUTE    GASTRO-ENTERIC    INTOXICATION  203 

illustrated  in  the  histories  above  given.  Our  efforts  are  to  be  directed 
toward  supporting  the  patient  by  the  use  of  stimulation,  given  hypoder- 
mically  or  by  the  stomach,  and  by  the  use  of  a  milk-free  diet,  powerful 
laxatives,  and  frequent  colon  flushings.  Castor  oil  may  be  required 
repeatedly,  and  should  be  given  freely  in  doses  of  at  least  one-half 
ounce  every  twelve  hours,  until  four  or  five  passages  in  twenty-four 
hours  result.  Bicarbonate  of  soda  (p.  197)  is  given  with  satisfactory  re- 
sults in  cases  of  this  type.  While  the  fever,  prostration,  and  bowel  inac- 
tivity persist,  it  is  necessary  to  continue  the  irrigations.  In  a  few  cases 
apparently  better  results  were  secured  by  using  for  the  irrigations  cold 
water  (70°  to  80°F.),  with  the  addition  of  Epsom  salts,  one  ounce  to  the 
pint. 

Stimulants. — Because  of  the  tendency  to  convulsions  and  nervous 
irritabihty,  strychnin  should  not  be  given.  The  tincture  of  strophan- 
thus  answers  better  than  any  other  heart  stimulant.  Alcohol  should  be 
used  onljT-  under  the  most  urgent  conditions  of  prostration.  Atropin 
sulphate,  from  3^f  ooo  to  >^oo  grain  given  hypodermically,  is  probably 
our  most  valuable  means  of  stimulation.  It  may  be  repeated  at  four- 
to  six-hour  intervals.  A  combination  of  tincture  of  strophanthus  and 
brandy,  or  digitalin  and  brandy,  given  hypodermically  is  of  value. 
For  a  child  six  months  of  age  20  minims  of  brandy  with  1  drop  of  tinc- 
ture of  strophanthus,  or  20  minims  of  brandy  with  3^oo  grain  digitalin, 
may  be  given  and  repeated  every  two  hours  if  necessary,  according  to 
the  requirements  of  the  case'.  After  the  first  year  children  may  be 
given  as  much  as  ^^^-foo  grain  of  digitalin  or  2  drops  of  the  tincture  of 
strophanthus. 

Irrigation  of  the  colon  (p.  793)  is  a  measure  of  inestimable  value, 
both  for  its  immediate  local  effect  and  also  for  increasing  general  peri- 
stalsis and  thus  emptying  the  small  intestine.  An  increase  of  the  peri- 
stalsis is  sometimes  well  secured  by  the  following  procedure :  After  the 
colon  is  washed  with  a  normal  salt  solution  at  a  temperature  of  95°F., 
the  tube  is  introduced  as  far  as  possible  and  8  ounces  of  water  at  60°F. 
is  allowed  to  escape.  The  tube  is  immediately  removed  and  an  at- 
tempt is  made,  by  elevating  the  buttocks  and  pressing  them  together, 
to  have  the  child  retain  the  solution  for  a  few  moments. 

In  using  nutrient  enemata  and  in  colon  flushing  for  purposes  of 
supplying  fluids  to  the  circulation  we  have  found  that  the  solution  is 
best  retained  when  introduced  warm — at  a  temperature  of  about 
100°F.  The  cooler  the  solution,  the  more  quickly  is  it  expelled  through 
exciting  peristalsis.  This  fact  may  be  taken  advantage  of  in  these 
cases  of  bowel  inactivity.  After  an  enema  of  cool  water  peristalsis  of 
the  small  intestine  will  often  result  in  the  passage  of  a  considerable 
quantity  of  its  contents  into  the  colon,  to  be  expelled  later  with  the 
water.  This  I  have  frequently  demonstrated.  The  action  of  the  cool 
water  will  be  further  assisted  by  light  abdominal  massage  maintained 
after  the  tube  is  removed.  Recovery  may  follow  the  clearing-out  of 
the  intestine,  or  an  ileocolitis  may  result,  as  in  gastro-enteric  intoxica- 
tion.    The  process  of  transition  may  require  but  a  surprisingly  short 


204  THE    PRACTICE    OF    PEDIATRICS 

time,  and  if  recovery  is  not  prompt,  an  ileocolitis  will  almost  certainly 
be  the  outcome. 

Upon  resuming  the  milk  diet  the  precautions  relating  to  the  use  of 
cow's  milk,  referred  to  under  Acute  Gastro-enteric  Intoxication  (p. 
193),  must  be  observed. 

ACUTE  INTESTINAL  INDIGESTION 

This  disorder  is  referred  to  first  because,  according  to  my  observa- 
tion, of  all  the  intestinal  disorders,  it  is  the  most  frequently  seen. 
Because  its  importance  is  not  recognized  the  prophylaxis  and  treatment 
receive  but  little  consideration.  The  proper  appreciation  and  man- 
agement of  a  disordered  intestinal  function  are  essential  to  the  solution 
of  that  most  important  problem — summer  mortality  from  diarrheal 
diseases.  As  pointed  out  elsewhere,  the  most  fertile  field  for  later  dis- 
ease is  furnished  by  the  intestine  which  is  persistently  deranged. 

In  June  the  mortality  from  acute  intestinal  disease  in  Greater  New 
York  in  children  under  two  years  of  age  is  usually  but  300  to  500  less 
than  in  August.  The  high  June  mortality  has  been  explained  by  the 
fact  that  the  list  included  many  cases  of  malnutrition  and  marasmus, 
but  it  must  be  remembered  that  the  list  includes  also  cases  with  dimin- 
ished intestinal  resistance,  which  are  ready  victims  to  the  almost  invari- 
able exposure,  through  infected  food,  to  which  every  bottle-fed  infant  is 
subjected  at  some  time  during  the  summer,  when  heat  and  humidity 
aid  in  lowering  the  general  vitality.  A  close  investigation  of  hundreds 
of  cases  of  severe  acute  intestinal  disorders  of  infants  has  shown  that 
a  great  majority  are  not  so  acute  as  a  superficial  history  would  indi- 
cate. A  complete  history  in  a'  case  of  acute  gastro-enteric  intoxica- 
tion (cholera  infantum),  or  in  one  of  apparently  severe  intestinal  in- 
fection with  resulting  colitis,  or  one  of  acute  colitis  (dysentery),  will 
show  that  the  child  had  defective  intestinal  digestion  during  the  pre- 
vious cold  months,  and  that  the  grave  condition  which  he  presented 
when  brought  for  treatment  had  been  preceded  for  two  or  three  or  more 
days  by  simple  diarrhea,  probably  without  vomiting  and  with  little 
fever.  The  fact  that  the  patient  did  have  green  passages  and  did  have 
diarrhea  proves  the  existence  of  intestinal  indigestion  before  the  urgent 
symptoms  of  fever  and  prostration  developed.  In  about  1  per  cent,  of 
the  cases  of  severe  gastro-enteric  diseases  of  children  in  summer  the 
onset  is  sudden  without  warning,  and  with  urgent  symptoms. 

Symptoms. — Temperature  is  usually  present  in  varying  degree. 
It  may  be  as  high  as  104°  or  105°F.  There  is  restlessness,  abdominal 
pain,  and  moderate  prostration.  The  stools  are  frequent,  undigested, 
green,  and  may  contain  mucus. 

Duration. — Properly  managed,  the  case  has  but  a  few  days'  dura- 
tion. The  temperature  readily  subsides,  and  the  child  soon  shows 
evidence  of  displeasure  at  the  reduced  diet. 

Prognosis. — The  condition  is  serious  only  in  the  sense  that  it  may 
be  the  starting-point  of  severe  intestinal  intoxication.  Properly  treated 
cases  present  few  dangers. 


PERSISTENT    INTESTINAL    INDIGESTION  205 

Treatment. — The  time  to  treat  these  cases  of  intestinal  indigestion, 
in  order  to  secure  most  effective  prevention  of  severe  toxemia  and  grave 
lesions,  is  before  the  physician  sees  the  patient.  The  reduction  in  the 
mortality  rests  in  the  education  of  the  mother  to  the  point  of  reahzing 
that  a  loose  green  stool  is  a  danger-signal.  When  it  occurs,  she  is  to 
give  a  dose  of  castor  oil  (two  teaspoonf uls) ,  stop  the  bottle  or  stop  the 
nursing,  and  give  the  baby  boiled  water  or  barley-water  until  the  physi- 
cian can  see  the  patient.  Any  physician  who  has  children  under  his 
care,  whether  in  hospital,  institution,  out-patient,  or  private  practice, 
and  who  does  not  so  instruct  the  nurse  or  mother,  fails  in  his  obligation 
as  a  practitioner  of  medicine. 

In  the  Breast-fed. — Intestinal  disease  of  severity  in  infants  fed  en- 
tirely on  breast-milk  is  exceedingly  rare.  With  a  breast-fed  baby  it 
may  be  necessary  to  discontinue  nursing  for  from  twelve  to  thirty- 
six  hours.  The  child  is  given  one  or  two  drams  of  castor  oil,  and  barley- 
water  or  rice-water  No.  1  (see  p.  70),  to  each  pint  of  which  3-^  or  }'i 
ounce  of  cane-sugar  is  added.  While  nursing  is  discontinued  the 
breasts  should  be  pumped  at  the  regular  nursing  hour  so  as  to  keep  up 
the  flow  of  milk  and  relieve  the  pressure.  Rarely  will  other  treatment 
be  required. 

The  Bottle-fed. — With  the  bottle-fed  greater  caution  will  be  necessary. 
The  management  consists  in  continuing  the  carbohydrate  diet,  which 
the  well-trained  mother  has  instituted,  until  the  stools  approximate 
the  normal.  This  may  necessitate  an  abstinence  from  milk  for  three 
or  four  days,  by  which  time  it  may  usually  be  resumed.  The  milk 
should  alv/ays  be  given  in  reduced  quantities  for  the  succeeding  day. 
One-half  ounce  of  skimmed  milk  may  be  added  to  every  second  feed- 
ing or  to  every  feeding  of  the  gruel.  If  it  is  well  digested  and  causes 
no  return  of  the  diarrhea,  the  amount  of  milk  may  be  increased  ten- 
tatively every  day  or  two  by  the  addition  of  one-half  ounce  to  each 
feeding. 

In  some  of  these  cases  the  diarrhea  without  fever  will  continue. 
In  such  instances  the  administration  of  10  grains  of  bismuth  subnitrate 
(Squibb 's),  with  3^  to  3'^  grain- of  Dover's  powder  at  two-  to  three- 
hour  intervals,  aids  materially  in  establishing  the  normal  intestinal 
function. 

PERSISTENT  INTESTINAL  INDIGESTION 

The  greater  part  of  this  subject  has  been  covered  in  the  considera- 
tion of  the  management  of  malnutrition  and  marasmus.  It  is  again 
referred  to  here  in  order  to  call  attention  to  those  conditions  which, 
though  mild  in  character,  constitute  so  important  an  etiologic  factor 
in  the  acute  intestinal  diseases  of  summer.  There  is  perhaps  not  enough 
bowel  disturbance  to  interfere  with  the  nutrition,  but  we  have  learned 
that  a  considerable  part  of  the  summer  mortality  of  acute  intestinal 
diseases  occurs  in  children  who  have  a  reduced  intestinal  resistance 
as  a  result  of  persistent  intestinal  indigestion. 

A  considerable  number  of  infants  do  not  have  a  normal  bowel  evac- 


206  THE    PRACTICE    OF    PEDIATRICS 

uation  even  for  two  days  out  of  ten.  There  is  constipation,  which  is 
neglected,  or  there  is  passage  of  undigested  or  loose  stools.  In  some 
cases  constipation  alternates  with  diarrhea.  Occasionally  there  is  a 
sharp  attack  of  diarrhea  with  fever.  In  getting  the  history  of  our  cases, 
regardless  of  the  nature  of  the  illness,  we  often  learn  that  the  infants 
have  undigested  stools.  There  is  a  tendency  to  an  unstable  intestinal 
equiHbrium.  This  condition  of  intestinal  indigestion  is  almost  without 
exception  due  to  errors  in  diet  involving  the  habitual  giving  of  unsuita- 
ble articles  of  food,  or  of  food  too  strong,  or  feeding  at  too  short 
intervals. 

Treatment. — The  management  of  each  case  is  determined  by  the 
age  of  the  patient  and  the  conditions  of  the  family,  and  is  discussed 
in  the  sections  relating  to  Nutrition,  Substitute  Feeding,  and  Modi- 
fication and  Adaptation  of  Foods. 

ft 

PERSISTENT  INTESTINAL  INDIGESTION  IN  OLDER  CHILDREN 

In  these  cases  there  is  a  disturbance  of  function  and  there  may  be 
suflEicient  absorption  of  toxins  of  an  unknown  nature  from  the  intestinal 
canal  to  produce  a  wide  range  of  symptoms.  Whether  this  causes 
pathologic  conditions  in  other  organs  it  is  not  possible  to  state.  It  is 
assumed,  however,  that  such  is  the  result.  Comparatively  little  atten-^ 
tion  appears  to  have  been  given  the  subject.  There  is  no  doubt  what- 
ever that  it  is  a  factor  of  great  importance  in  the  nutritional  and 
so-called  functional  nervous  disorders  of  childhood.  One  reason  why- 
little  attention  has  been  called  to  the  intestinal  tract  as  an  etiologic 
factor  is  perhaps  because  the  child  is  not  necessarily  constipated.  In- 
testinal toxemia  may  exist  with  one  or  two  apparently  normal  passages 
daily,  and  even  without  the  presence  of  indican  in  the  urine. 

Pain  is  not  a  necessary  symptom.  It  is  occasionally  present,  how- 
ever, as  is  also  abdominal  discomfort  involving  a  sensation  of  con- 
striction and  pressure. 

In  my  cases  the  conditions  in  which  intestinal  toxemia  has  seemed 
to  play  a  part  sufficient  to  form  a  symptom-complex  have  been  habitual 
headache,  disorders  of  speech,  choreic  in  character,  secondary  anemia, 
habitual  sleep-talking,  sleep-walking,  and  general  irritability  without 
apparent  cause.  Well  children  are  naturally  bright  and  happy.  When 
a  child  is  persistently  cross  and  irritable,  he  is  not  a  well  child.  Chronic 
papular  eczema  has  proved  to  be  of  intestinal  origin  in  a  considerable 
number  of  my  cases,  particularly  among  the  out-patient  class.  The 
condition  often  regarded  and  treated  as  malaria  is  not  infrequently 
due  to  intestinal  toxemia.  Fever  of  a  degree  or  two  may  be  present 
for  protracted  periods.  Nearly  every  case  which  has  come  under  my  care 
had  been  given  at  some  time  or  other  a  course  of  quinin.  Such  a  pa- 
tient is  very  apt  to  be  habitually  tired  and  languid.  He  may  be  fairly 
bright  early  in  the  day,  but  in  the  afternoon  he  yawns  and  complains 
of  being  tired  and  sleepy.  The  blood  examination  fails  to  reveal  signs 
of  malarial  infection,  and  quinin  in  full  doses  furnishes  no  relief.     The 


PERSISTENT    INTESTINAL    INDIGESTION  207 

appetite  may  be  satisfactoiy,  the  tongue  may  show  no  signs  of  digestive 
disorder,  although  such  is  rarely  the  case.  The  tongue  is  usually  coated 
and  the  appetite  capricious.  The  symptom-complex  which  suggests 
to  the  mother  the  thought  of  worms  is  usually  the  manifestation 
of  intestinal  toxemia. 

Illustrative  Cases. — -An  interesting  case  of  this  nature  came  under  my  care  a  few- 
years  ago.  The  boy,  aged  three  years,  highly  nervous  and  irritable,  was  afflicted 
with  day  terrors — pavor  diurnus.  The  attention  of  the  nurse  was  attracted  to  the 
condition  by  the  boy,  who  asked  that  the  "bugs"  be  removed  from  his  lap-robe 
when  he  was  in  his  go-cart.  The  time  was  mid-winter,  and  there  were  no  bugs 
present.  I  fortunately  saw  the  boy  on  one  of  these  occasions  and  asked  him  to 
pick  up  a  bug,  which  he  tried  to  do  with  his  fingers.  He  could  not  understand 
why  he  could  not  catch  them.  In  this  child  the  tongue  was  heavily  coated  and 
there  was  moderate  constipation,  a  laxative  being  required  every  third  day.  There 
was  an  excess  of  indican  in  the  urine.  The  boy  was  taking  a  large  amount  of  rich 
cow's  milk  daily.  After  stopping  this,  a  full  dose  of  rhubarb  and  soda  was  given 
daily  and  he  was  well  in  a  week. 

A  boy  five  years  old  was  brought  to  me  because  of  disturbance  of  speech.  He 
was  normal  until  three  and  one-half  years  of  age,  when  he  had  difficulty  in  the 
formation  of  entire  words.  This  had  increased  with  the  development  of  other 
nervous  phenomena.  There  was  marked  incoordination  in  speech — dysarthria — 
due  to  choreic  movements  evidently  of  the  tongue  and  laryngeal  muscles.  The 
boy  was  exceptionally  well  nourished  and  there  was  an  absence  of  choreic  move- 
ments in  other  parts  of  the  body.  The  knee  reflexes  were  considerably  increased. 
He  was  easily  excited.  Hard  play  was  followed  by  restless  nights,  and  he  talked  in 
his  sleep  every  night,  regardless  of  the  habits  of  the  day.  Inquiry  into  the  diet 
failed  to  reveal  any  grave  errors.  He  drank  one  quart  of  milk  daily,  although  milk 
had  never  agreed  with  him  as  an  infant.  The  bowels  moved  once  daily.  The  move- 
ments were  often  of  foul  odor,  and  the  mother  stated  that  she  was  satisfied  they 
were  too  small.  The  case  after  three  weeks  showed  striking  improvement  on  a 
diet  without  milk,  with  a  daily  laxative,  and  made  a  complete  recovery  in  three 
months. 

A  third  patient  was  a  girl  six  years  of  age  who  lived  in  the  best  surroundings, 
in  a  country  district.  She  was  pale,  rather  thin,  and  below  weight  for  her  age. 
She  had  been  chronically  tired  and  irritable  for  two  years.  The  blood  showed 
the  existence  of  a  secondary  anemia,'  and  the  urine  contained  a  marked  excess  of 
indican.  She  had  been  taking  quantities  of  quinin.  There  was  no  constipation. 
Her  appetite  was  indifferent.  She  favored  milk  and  was  paid  for  drinking  extra 
quantities  of  it,  about  two  quarts  daily  being  taken.  Marked  improvement  fol- 
lowed the  withdrawal  of  milk  from  the  diet  and  the  use  of  laxatives,  after  which 
she  passed  from  my  observation. 

In  many  cases  of  this  nature  there  is  a  milk  intolerance,  perhaps 
both  for  the  fat  and  protein. 

Treatment. — In  my  experience  the  management  of  these  cases, 
which  has  been  most  successful,  has  consisted  in  the  discontinuance 
of  cow 's  milk,  with  the  further  dietetic  restriction  to  but  one  egg  every 
second  day,  and  meat  but  once  daily.  Cereals,  fruit,  and  vegetables 
are  taken  as  suggested  in  the  dietary  (p.  105).  The  use  of  green  vege- 
tables is  particularly  encouraged.  In  place  of  cow's  milk,  malted  milk 
is  given,  and  to  facilitate  the  bowel  action  a  raw  apple  is  given  in  the 
middle  of  the  afternoon.  The  patient  takes  an  after-dinner  rest  for 
an  hour  or  two.  If  constipation  is  obstinate,  rhubarb  and  soda  of  the 
following  strength  are  used: 

I^     Pulveris  rhei gr.  iv 

Sodii  bicarbonatis gr.  viij 

Syrupi  rhei  aromatici 3ss 

Aquse q.  s.  ad  3  j 

M.  Sig. — One  teaspoonful  once  or  twice  daily. 


208  THE    PEACTICE    OF   PEDIATRICS 

If  the  patient  can  take  a  capsule,  I  prefer  the  following  for  a  child 
from  five  to  eight  years  of  age : 

I^     Tincturse  belladonnse gtt.  ij 

Tincturse  nucis  vomicae gtt.  iv 

Extract!  cascarse  sagradse gr.  j-iij 

Sodii  bicarbonatis gr.  iij 

M.  ft.  capsula  no.  i. 

Sig. — To  be  taken  at  bedtime. 

The  medication  may  be  continued  for  three  or  four  weeks,  after 
which  time  one  dram  of  the  syrup  of  the  hypophosphites  (Gardner's) 
may  be  given  three  times  a  day.     This  may  be  alternated  with : 

I^     Ferri  et  ammonii  citratis gr.   xxiv 

Elix.  simplicis 5j 

Aquae q.  s.  ad  5iv 

M.  Sig. — One  teaspoonful  three  times  daily  after  meals. 

In  the  event  of  constipation  persisting  after  the  use  of  the  laxative, 
the  oil  treatment  (p.  241)  may  be  brought  into  use  and  continued  until 
the  condition  is  relieved. 

MECHANICAL  AGENCIES  IN  THE  INTESTINAL  TRACT  AS  A  CAUSE 
OF  DIGESTIVE  DISTURBANCES 

Observation  with  the  Roentgen  ray  in  association  with  constant 
clinical  supervision  has  opened  up  an  entirely  new  field  in  the  etiology 
of  the  persistent  intestinal  disorders  in  children.  As  a  result  of 
abnormalities  in  structure  and  in  the  relations  of  various  portions  of 
the  intestine  there  results  a  derangement  of  function  due  to  disturbed 
physiological  and  chemical  processes,  the  result  being  in  many 
instances  faulty  nutrition,  defective  growth  and  inferior  general 
development  of  the  child,  both  physical  and  mental. 

Mechanical  defects  of  the  intestine  such  as  ptosis  of  the  colon, 
dilatation  of  the  colon,  dilated  caecum  and  the  long  sigmoid  are  the 
abnormalities  most  frequently  encountered.  The  ptosed  colon  is 
usually  associated  with  dilatation  and  ptosis  of  the  stomach  and  is 
probably  secondary  to  that  condition. 

The  long  sigmoid  (Figs.  19,  20,  21,  22)  is  of  congenital  origin.  The 
dilated  colon  and  caecum  appear  to  be  dependent  upon  the  accumu- 
lation of  feces  and  gases  brought  about  by  the  obstruction  occasioned 
by  the  long  sigmoid,  with  its  angulation  and  defective  peristalsis. 

Symptoms. — The  symptoms  referable  to  the  above  abnormalities 
are  repeated  attacks  of  acute  indigestion  with  vomiting,  abdominal 
distention,  habitual  or  intermittent,  intestinal  colic,  constipation  which 
may  be  extreme,  diarrhea  alternating  with  constipation,  or  habitually 
loose  mucous  evacuations,  periodic  fever  with  intestinal  association. 

In  addition  to  these  active  manifestations  the  patients  are  usually 
anemic — there  is  secondary  malnutrition,  the  child's  mental  equihbrium 
is  easily  disturbed,  they  are  apt  to  be  unhappy  irritable  children, 
they  sleep  poorly  and  their  appetite  is  capricious.  A  few  show  defects 
in  stature.     That  arrested  growth  and  anemia  may  be  the  result  of 


MECHANICAL   AGENCIES   IN   THE    INTESTINAL   TRACT         209 

abnormal  intestinal  function  is  readily  understood  when  one  realizes 
what  a  vital  part  the  intestine  plays  in  growth  and  development. 


Fig.  19. — Female    aged    9    years.     Elongated    sigmoid, 
transverse    colon     (LeWald) 


Passes    above   level    of 


The  history  of  the  case  represented  in  Fig.  19  is  as  follows:  A  girl 
aged  9  years  and  weighing  54  pounds  showed  hemoglobin  40  per  cent. 
14 


210 


THE    PRACTICE    OF    PEDIATRICS 


and  red  blood  cells  4,000,000.     She  was  of  delicate  appearance,  had 
moderate  malnutrition  and  showed  very  slow  gain  in  weight.     About 


Fig.  20. — Female  aged  2)4.  years.  "Double-barreled"  transverse  colon. 
Appearance  due  to  elongated  sigmoid  flexure  passes  across  to  right  side  of  abdomen 
and  above  crest  of  right  ihac  bone  (LeWald). 

every  two  months  she  had  so-called  bilious  attacks  simulating  recurrent 
vomiting.  There  was  high  fever  and  she  was  in  bed  for  several  days 
each  time.     The  bowels  were  habitually  constipated  and  daily  medi- 


MECHANICAL   AGENCIES    IN   THE    INTESTINAL   TRACT        211 


cation  was  required.  The  breath  was  offensive.  The  Roentgen  ray- 
revealed  ptosis  of  the  stomach  and  that  it  failed  to  empty  itself  in 
seven  hours.  There  was  marked  ptosis  of  the  transverse  colon  and 
marked  elongation  of  the  sigmoid. 


Fig.  21. — Female  aged  15  months.     Figure  of  8  sigmoid  flexure  (LeWald). 

Fig.  20.  A  girl,  aged  2^^  years,  weighing  25  pounds,  showed  hemo- 
globin 55  per  cent,  and  red  blood  cells  4,600,000.  There  was  moderate 
malnutrition.  She  had  three  convulsions  of  gastro-intestinal  origin  in 
the  previous  year.  There  was  habitual  constipation  and  medication  or 
an  enema  was  required  daily.     The  urine  showed  a  moderate  amount 


THE    PRACTICE    OF   PEDIATRICS 


Fig.  22.— Male  aged  3^  years.     Elongated  sigmoid.     One  of  the  most  extreme 
types  encountered.     Roentgenogram  by  Dr.  L.  T.  LeWald. 


MECHANICAL    AGENCIES    IN    THE    INTESTINAL    TRACT         213 

of  acetone.  The  Roentgen  ray  revealed  an  elongated  sigmoid  passing 
2  inches  above  the  umbilicus.  When  the  child  was  in  the  prone  posi- 
tion the  sigmoid  passed  to  the  right  as  far  as  the  abdominal  wall. 

Fig.  21.  A  girl,  15  months  of  age,  was  brought  from  a  distant 
city  because  of  loose  evacuations  containing  blood  and  mucus.  This 
condition  had  existed  for  one  month  and  had  been  preceded  by  the 
most  obstinate  constipation.     Medication  had  been  required  daily. 

Fig.  22.  A  boy,  33-^  years  of  age,  weighing  32  pounds  (under 
treatment  at  the  present  time)  represents  a  markedly  elongated  and 
prolapsed  sigmoid. 

The  history  given  by  the  mother  is  as  follows:  Boy  has  had 
acute  gastro-intestinal  attacks  since  birth,  vomiting,  diarrhea  and  fever, 
acute  seizures  lasting  3  to  4  days  during  which  he  loses  a  pound  or 
two  of  weight.  During  the  past  year  there  has  not  passed  two  months 
without  such  an  illness.  Between  attacks  is  constipated  and  requires 
medication.  Has  frequent  pains  in  abdomen  and  appendicitis 
has  been  diagnosed.  Breath  habitually  offensive,  tongue  habitually 
coated.  Some  of  these  seizures  have  been  diagnosed  as  colitis  because 
of  the  presence  of  considerable  quantities  of  mucus.  Very  irritable 
and  very  unhappy  in  disposition.  Abdomen  distended  a  greater  part 
of  the  time. 

Constipation  alone,  or  with  abdominal  distention,  are  present 
in  nearly  all.  In  those  with  diarrhea  or  habitually  loose  mucus 
evacuations  there  is  always  a  history  of  previous  constipation,  and 
the  relief  of  the  constipation  is  the  keynote  of  the  management. 

Treatment  for  Constipation. — The  selection  of  suitable  food  for  a 
given  case  plays  a  large  part  in  the  management.  For  the  constipation 
the  following  dietetic  regulations  are  advised:  White  bread,  toast 
and  crackers  are  omitted.  Oatmeal,  cornmeal,  hominy,  cracked  wheat 
and  the  coarse  cereals  are  allowed.  Potatoes,  rice,  milk  and  eggs  are 
given  sparingly.  Milk  is  often  replaced  by  malted  milk.  Green 
vegetables  are  given  twice  a  day.  Stewed  or  raw  fruits  are  given  the 
preference  as  desserts.  Fresh  meats  and  fish  are  allowed.  Whole 
wheat  bread  and  oatmeal  crackers  are  advised.  Raw  fruits  are  given 
with  the  stomach  supposedly  empty,  an  hour  to  an  hour  and  a  half  be- 
fore meals.  We  have  found  the  giving  of  raw  fruits  with  the  stomach 
empty  one  of  the  most  valuable  dietetic  means  of  managing  constipa- 
tion. We  are  speaking  now  of  those  cases  without  stomach  in- 
volvement. 

Enemata  for  Temporary  Purposes. — An  enema  may  be  employed 
but  it  should  never  be  given  habitually.  I  have  seen  marked  dilata- 
tion of  the  rectum  as  a  result  of  frequent  enemata. 

Massage. — Properly  applied,  daily  massage  is  almost  indispensable 
in  obstinate  cases.  Massage  and  suitable  diet  may  have  to  be  contin- 
ued for  several  months. 

Medication. — Olive  oil  and  liquid  alboline  are  useful  in  connection 
with  other  laxatives,  but  rarely  sufficient  when  used  alone.  What 
is  required  is  an  active  peristalsis.     In  using  laxatives  however,  care 


214  THE    PRACTICE    OF    PEDIATRICS 

is  to  be  exercised  to  avoid  purgation.  Our  best  results  have  been  in 
the  use  of  fluid  ext.  aromatic  cascara  sagrada  three  times  daily 
after  meals,  given  in  doses  sufficient  to  produce  one  or  two  free  evacua- 
tions daily.  Given  with  an  oil  and  with  the  aid  of  massage  the  cascara 
may  be  gradually  reduced.  It  should  always  be  given  after  each  meal 
no  matter  how  small  the  daily  dosage. 

Diarrhea. — The  child  with  diarrhea  or  with  habitually  loose  evacua- 
tions perhaps  but  one  or  two  daily  is  best  treated  by  omitting  stewed 
fruits  and  green  vegetables  entirely  from  the  diet.  Milk  given  these 
patients  should  be  skimmed  and  boiled.  My  earlier  results  with  this 
type  of  case  were  very  satisfactory.  Two  cases  under  treatment  at 
the  present  time,  both  of  which  have  greatly  elongated  sigmoids,  are 
proving  intractable  and  not  much  progress  is  being  made  with  diet  and 
medication.     Surgical  procedures  may  be  required  in  these  patients. 

Although  there  may  be  a  displaced  colon  or  an  elongated  sigmoid, 
and  a  history  of  previous  constipation,  the  stool  should  always  be 
examined  in  diarrhea  for  other  possible  causative  factors. 

COLIC 

Few  children  complete  their  first  year  without  having  severe 
attacks  of  intestinal  colic.  In  some  cases  the  child  thrives  in  spite  of 
the  attacks,  in  others  such  a  grave  degree  of  indigestion  exists  that  the 
condition  may  prove  most  serious.  The  character  of  both  human  and 
cow 's  milk,  its  ready  decomposition  in  the  intestine,  with  the  formation 
of  gas,  together  with  the  lack  of  development  of  the  infant's  digestive 
apparatus,  explain  in  no  small  degree  the  frequency  of  colic  in  the  young. 
When  cow 's  milk  is  used  as  in  the  bottle-fed,  we  are  dealing  with  a  sub- 
stance foreign  to  the  infant 's  digestive  apparatus,  and  often  colic  is  the 
outcome.  Any  condition  that  will  give  rise  to  indigestion  may,  of 
course,  be  a  cause  of  colic.  Children  who  take  too  much  milk,  too 
strong  milk,  or  who  take  milk  too  frequently  are  the  usual  subjects 
of  colic.  Probably  the  most  frequent  cause  of  colic  is  indigestion 
of  the  proteid  of  the  milk.  Either  the  proteid  is  in  excess  or  the  child 
has  poor  proteid  capacity.  Not  a  few  cases  of  colic  are  due  secondarily 
to  defective  bowel  action.  A  passage  occurs  each  day,  but  in  too  small 
amount.  There  is  a  continual  fecal  residue  in  the  intestine  which  under- 
goes decomposition  with  gas-formation.  Cold  feet  are  often  associated 
with  colic.  Fright,  anger,  fatigue,  excitement- — any  condition,  in  short, 
which  may  make  a  sufficiently  unfavorable  impression  upon  the  child 's 
nervous  organism — may  produce  indigestion  and  colic. 

Likewise  any  adverse  nervous  mental  state  in  the  mother  may  pro- 
duce colic  in  the  breast  baby.  Constipation  in  the  mother  is  not  an 
infrequent  cause. 

Infants  who  have  colic  habitually  will  more  often  have  it  late  in 
the  day  than  at  any  other  time. 

Colic  may  be  caused  by  an  elongated  sigmoid  which  forms  angula- 
tions and  prevents  the  natural  passage  of  gas.  Fig.  12  represents  a 
case  of  most  obstinate  and  severe  colic.     The  patient,  a  girl,  aged 


COLIC  215 

33^^  months,  weighing  10  pounds,  was  suffering  from  malnutrition, 
extreme  cohc  night  and  day,  and  constipation.  An  enema  was  re- 
quired daily.  The  Roentgen  ray  I'evealed  hyperperistalsis  of  stomach. 
The  sigmoid  was  elongated,  passing  1  inch  above  the  umbilicus,  and 
the  stomach  was  distended  with  gas. 

Diagnosis. — While  the  diagnosis  is  usually  a  simple  matter  it  must 
be  remembered  that  intussusception  (p.  233)  and  appendicitis  (p.  252) 
may  cause  symptoms  identical  with  colic. 

Treatment. — Repeatedly  I  have  had  under  my  care  nursing  babies 
who  suffered  from  habitual  colic  and  who  recovered  after  the  regulation 
of  the  mother's  bowels  by  exercise,  diet,  and  medication.  In  breast- 
fed cases  in  which  the  mother's  milk  upon  repeated  examination 
proves  too  strong  and  the  child  suffers  from  daily  colic,  a  dilution  of 
the  milk  may  be  made  by  the  use  of  plain  water  or  barley-water,  from 
one-half  ounce  to  one  and  one-half  ounces  of  the  diluent  being  given 
before  each  nursing.  In  addition  the  bowels  of  the  colicky  infant 
should  be  made  to  move  at  least  twice  daily,  morning  and  evening. 
When  this  does  not  take  place  readily  a  simple  laxative  such  as  milk 
of  magnesia,  one-half  to  one  teaspoonful,  or  10  to  30  drops  of  aromatic 
cascara  sagrada,  may  be  given  daily.  Under  no  condition  should  a 
child  subject  to  colic  be  allowed  to  go  without  a  bowel  evacuation  for 
more  than  twenty-four  hours. 

Diet. — The  dietetic  management  of  colic  in  the  bottle-fed  consists 
in  adapting  the  food  to  the  child 's  digestive  capacity.  The  bottle  baby 
may  have  habitual  colic  moderately  and  thrive,  but  is  receiving  an 
imperfectly  adapted  food.  Here,  as  in  the  breast-fed,  the  condition  is 
usually  dependent  upon  an  excessive  casein  supply  or  a  diminished 
casein  capacity.  The  matter  of  the  adjustment  of  cow's-milk  proteid 
in  indigestion  is  discussed  in  detail  under  Milk  Adaptation  (p.  62). 
It  is  sufficient  to  say  that  the  colicky  bottle  baby  should  have  long 
intervals  between  feedings — usually  one-half  hour  longer  than  other- 
wise allowed.  Digestion  is  slow  in  many  of  these  cases,  although 
in  other  respects  they  may  be  healthy  children.  In  some  the  indigestion 
and  pain  are  so  severe  that  a  perfect  adaptation  of  cow 's  milk  is  impos- 
sible, and  some  other  food  than  cow's  milk  will  be  required.  The 
prevention  of  colic,  then,  it  will  be  seen,  rests  upon  a  proper  adjust- 
ment of  the  food. 

Enemas. — The  immediate  attack  is  usually  best  relieved  by  the  use 
of  an  enema  at  110°F.  of  a  normal  salt  solution  or  of  soapsuds,  which, 
by  inducing  a  movement  of  the  bowels,  allows  the  gas  to  escape. 

Medication. — A  soda-mint  tablet  dissolved  in  one  ounce  of  hot 
water  given  in  one-teaspoonful  doses  repeated  at  five  minute  intervals 
is  sometimes  efficacious.  For  a  child  under  one  year  of  age  3  drops  of 
spiritus  83theris  compositus  (Hoffmann's  anodyne)  may  be  given  in  2 
teaspoonfuls  of  hot  water  and  repeated  at  ten-minute  intervals.  From 
5  to  10  drops  of  gin,  when  given  in  3  teaspoonfuls  of  hot  water,  may 
be  used,  and  repeated  in  from  ten  to  fifteen  minutes  if  the  attack 
continues. 


216  THE    PRACTICE    OF    PEDIATRICS 

Hot  Applications. — Hot  applications  to  the  abdomen  are  often  grate- 
ful to  the  patient.  For  this  purpose  10  drops  of  turpentine  in  one  quart 
of  water  at  120°F.  may  be  used  with  benefit.  A  flannel  is  wrung  out 
of  the  water  or  the  solution  and  applied  over  the  abdomen  and  covered 
with  a  dry  piece  of  flannel.  The  dressing  may  be  changed  every  ten 
or  fifteen  minutes. 

Opium  and  its  derivatives  should  not  be  used  in  the  treatment  of 
colic.  This  drug  may  relieve  the  pain  temporarily,  but  it  aggravates 
the  condition  to  which  the  colic  is  due. 

PREVENTION  OF  THE  ACUTE  INTESTINAL  DISEASES  OF  THE  SUMMER 

Preventive  medicine,  so  called,  is  at  the  present  time  engaging 
the  attention  of  the  best  medical  minds.  The  acute  intestinal  diseases 
of  summer,  with  their  large  infant  mortality,  offer  a  better  field  for 
life-saving  measures  than  does  any  other  department  of  pediatrics. 

Potent  etiologic  factors  in  summer  diarrhea  are  unfavorable  climate 
and  unfavorable  environment.  In  the  class  which  furnishes  the  largest 
mortality,  climate  cannot  be  changed  for  a  sufficient  number  to  exert 
any  great  influence  on  the  general  mortality.  Through  education 
the  environment  may  be  radically  improved,  but  it  cannot  be  changed. 
The  hot  months  come  and  the  tenement  child  must  remain  at  home. 
Excursions  and  outings  of  various  kinds  are  valuable  in  a  small  way  to 
comparatively  few,  as  the  child  must  return  to  the  tenement  home  at 
night  or  after  a  few  days'  absence,  so  that  in  our  consideration  of  this 
class  of  patients  in  large  cities  we  must  accept  unfavorable  environment 
and  hot  weather — in  other  words,  we  must  treat  these  cases  in  thejr 
homes.  Those  more  fortunately  situated,  who  can  have  the  advantage 
of  the  country  and  intelligent  care,  are  proportionately  less  liable  to 
diarrheal  diseases.  Other  than  climate  and  environment,  the  determin- 
ing etiologic  factors  among  all  classes  are:  first,  a  disordered  gastro- 
enteric tract;  second,  infected  food;  third,  faulty  feeding  methods; 
fourth,  an  absence  of  appreciation  on  the  part  of  the  parents  and 
physicians  of  the  fact  that  an  attack  of  diarrhea  or  vomiting,  or  even  a 
green,  undigested  stool,  occurring  in  an  infant  under  eighteen  months 
of  age  during  hot  weather,  is  to  be  looked  upon  as  a  serious  matter  re- 
quiring prompt  attention. 

Children  as  well  as  adults  are  frequently  exposed  to  disease  from 
sources  of  which  they  are  ignorant,  because  their  power  of  resistance 
is  insufficient  for  their  protection.  With  milk,  the  most  readily  in- 
fected of  all  nutritional  substances,  as  the  chief  article  of  diet,  it  may 
safely  be  assumed  that  few  infants  will  pass  through  the  heated  term 
without  being  subjected  repeatedly  to  infection  from  bacteria  suf- 
ficient to  produce  grave  illness.  An  infant's  best  safeguard  against  in- 
testinal infection  is  a  strongly  resistant  gut,  which  is  best  secured  by 
the  absence  of  digestive  disturbances  at  all  seasons  of  the  year.  Feed- 
ing and  intelligent  management  generally  throughout  the  year  has, 
consequently,  a  decided  bearing  upon  summer  mortality  from  intes- 
tinal diseases. 


PREVENTION   OF  ACUTE   INTESTINAL   DISEASES   OF   SUMMER        217 

I  have  had  abundant  opportunity  to  observe  that  the  children  who 
have  had  frequent  attacks  of  intestinal  indigestion  during  the  colder 
months  furnish  our  severe  cases  during  the  summer.  A  most  important 
feature,  then,  in  prophylaxis  is  to  teach  the  mother  how  to  feed  and 
care  for  the  child  all  the  year  round,  in  order  that,  by  keeping  well, 
the  child  may  maintain  a  high  grade  of  intestinal  resistance. 

Dispensary  Rules  of  Universal  Application. — At  the  out-patient 
department  of  the  Babies'  Hospital  and  the  New  York  Polyclinic,  I 
have  had  abundant  opportunity  to  come  into  close  contact  with  a 
great  many  tenement  mothers  and  tenement  children.  At  these  in- 
stitutions we  have  a  clientele  fairly  regular  in  attendance,  year  after 
year;  for  as  one  baby  after  another  appears  in  the  family,  each  is 
brought  to  us  for  treatment.  At  these  dispensaries  there  is  a  surprisingly 
low  summer  diarrhea  mortality,  because  we  teach  the  mothers  how  to 
feed  and  care  for  their  children  all  the  year  round.  They  are  taught 
the  value  of  fresh  air,  the  use  of  boiled  water  as  a  beverage,  and  the  bene- 
fits of  frequent  spongings  on  hot  days.  Both  private  and  dispensary 
mothers  whose  children  are  under  my  care  are  given  pamphlets  of  in- 
struction and  also  oral  teaching  bearing  on  these  points,  and  particularly 
those  relating  to  the  care  of  the  feeding  bottle  and  the  milk.  In  case 
special  articles  of  diet  are  to  be  given,  the  mothers  are  taught  how  to 
prepare  them.  Written  directions  are  always  given  covering  the  point; 
nothing  is  left  to  the  memory.  Each  mother  and  nurse  has  it  im- 
pressed upon  her  that  she  must  wash  her  hands  in  soap  and  water 
before  touching  the  baby 's  food  or  feeding  apparatus  for  any  purpose, 
and  that  there  must  be  a  covered  vessel  in  which  the  soiled  napkins  are 
to  be  kept  until  washed.  At  the  first  sign  of  intestinal  derangement, 
regardless  of  the  season  of  the  year,  they  are  taught  to  stop  the  milk 
at  once,  to  give  instead  a  cereal  water,  such  as  barley-water  or  rice- 
water,  and  a  dose  of  castor  oil.  It  is  impressed  upon  them  that,  in 
winter  as  well  as  summer,  a  green,  watery  stool  means  that  the  baby 
is  ill  and  needs  treatment.  When  the  mother  learns  the  above  lesson 
for  December,  January,  and  March,  she  will  not  forget  it  in  July. 
Furthermore,  as  a  result  of  the  immediate  correction  of  a  child's 
digestive  disorder  during  the  winter  months,  the  digestive  tract  affords 
a  much  less  fertile  field  for  pathogenic  bacteria  during  the  summer. 

Prompt  Treatment  Essential. — Comparatively  few  cases  of  intestinal 
diseases  have  pronounced  toxic  symptoms  at  the  outset.  At  first 
there  are  evidences  of  a  milk  infection  only.  There  may  be  vomiting, 
several  green,  watery  stools,  and  a  slight  elevation  of  temperature, 
or  the  symptoms  may  be  still  more  mild — only  one  or  two  loose  green 
defecations.  Prompt  treatment  at  this  time,  even  in  a  crowded  tene- 
ment, usually  means  prompt  recovery.  When  treatment  is  dela3'-ed 
and  the  administration  of  milk  is  continued,  severe  toxic  symptoms 
and  intestinal  lesions  are  almost  invariably  the  result. 

New  York  City  Experiments. — An  interesting  demonstration  of 
what  may  be  accomplished  by  proper  care  was  made  under  the  direc- 
tion of  Dr.  William  H.  Park,  of  the  New  York  Health  Department, 


218  THE    PRACTICE    OF    PEDIATRICS 

during  the  summer  of  1902.  Fifty  tenement  children,  ranging  from 
three  to  nine  months  of  age,  were  selected  for  the  experiment.  These 
children  were  all  fed  on  the  Straus  milk.  They  were  visited  two  or 
three  times  a  week  by  physicians  especially  assigned  to  them.  The 
mothers  were  carefully  instructed  as  to  the  care  of  the  milk  and  the 
feeding  apparatus,  and  in  other  necessary  details.  With  the  first 
signs  of  illness,  the  milk  was,  to  be  stopped,  the  physician  notified, 
and  suitable  treatment  instituted.  Among  these  50  tenement  children, 
all  under  one  year  of  age,  all  bottle-fed,  selected  at  random,  there  was 
not  one  death  during  the  summer.  This  valuable  observation  bears 
out  my  contention  that  the  deaths  from  summer  diarrhea  among  tene- 
ment children  may  be  greatly  reduced  by  the  use  of  good  milk  given 
under  proper  supervision,  supplemented  by  prompt  and  competent 
medical  care  at  the  first  sign  of  illness.  Perhaps  in  1  per  cent,  of  the 
cases  of  summer  diarrhea  a  very  severe  direct  infection  is  evident, 
and  the  condition  of  the  patient  is  very  grave  from  the  onset.  In  the 
remainder  the  invasion  is  gradual;  and,  if  the  warnings  are  heeded, 
the  illness  will  usually  terminate  quickly  in  recovery. 

How  to  Secure  Good  Milk. — To  those  of  my  patients  of  the  bet- 
ter class  who  go  to  the  country  for  the  summer,  and  who  have  cows 
of  their  own  in  order  to  control  their  milk-supply,  I"  give  the  following 
directions:  Before  milking,  the  udders  and  belly  of  the  cow  should  be 
wiped  with  a  damp  cloth  to  remove  clinging  particles  of  dirt.  It  is 
in  these  droppings  containing  manure  that  the  most  dangerous  forms 
of  bacteria  of  decomposition  enter  the  milk.  The  milker  should  wash 
his  hands  before  milking.  The  first  few  jets  of  milk,  coming  from  the 
ducts  near  the  openings,  are  apt  to  be  swarming  with  bacteria,  and  are, 
therefore,  discarded.  Immediately  after  the  milking  the  milk  should 
be  strained  through  several  thicknesses  of  cheese-cloth,  or  through  ab- 
sorbent cotton,  into  an  ordinary  milk  bottle,  which  is  at  once  placed  in 
a  pail  of  cracked  ice.  Such  simple  care  as  this,  even  on  an  ordinary 
farm,  gives  a  very  low  bacteria  count.  As  may  readily  be  seen,  it  is 
attended  with  very  little  trouble  and  expense.  Different  dairies  through- 
out the  country,  which  are  located  near  my  patients  for  the  summer, 
meet  the  above  requirements,  for  which  they  receive  an  extra  compen- 
sation of  five  or  six  cents  a  quart. 

The  Necessity  for  Education. — The  suggestions  we  have  offered  are 
all  included  under  the  one  general  heading  of  Education.  The  mother 
must  be  educated  how  to  live,  how  to  care  for  the  baby,  how  to 
clothe  and  bathe  him  during  the  summer.  It  must  be  impressed  upon 
her  that  he  needs  all  the  fresh  air  available.  She  must  be  educated  to 
the  point  of  knowing  what  to  do  at  the  first  sign  of  threatened  disease. 
Municipalities  must  be  educated  to  appreciate  their  responsibility  as 
factors,  negative  or  positive,  in  the  summer  mortality.  The  farmer 
must  be  educated  to  produce  safe  milk,  and  the  consumer  must  be 
educated  to  appreciate  its  value  and  pay  for  it.  Above  all  others,  the 
physician  must  be  educated  along  these  lines  so  as  to  be  able  to  teach 
the  mothers  how  to  do  right  in  the  care  of  their  children  all  the  year 
round. 


VOMITING  219 

VOMITING 

While  vomiting  does  not  constitute  a  disease  in  itself,  it  is  a  condi- 
tion of  such  frequency  in  children,  and  occurs  in  such  widely  varying 
circumstances,  that  any  work  relating  to  diseases  of  children  would 
be  incomplete  without  its  consideration. 

The  most  frequent  causes  of  vomiting  depend  solely  upon  the 
functions  of  the  stomach.  When  the  stomach  is  overfilled,  vomiting 
may  result.  When  substances  sufficiently  irritating  come  in  contact 
with  its  lining  mucous  membrane,  whether  they  are  swallowed  as 
such  or  are  produced  by  fermentation  or  some  other  change  in  the 
stomach  contents,  they  are  ejected.  When  there  is  an  inflammatory 
involvement  of  the  mucous  membrane  of  the  stomach,  either  acute  or 
chronic  in  character,  the  organ  becomes  intolerant  of  the  blandest  of 
fluids.  Another  condition  involving  the  structure  of  the  stomach,  but 
only  occasionally  seen  in  children,  is  ulceration,  which  is  usually 
multiple.     Vomiting  is  the  prominent,  in  fact  the  only,  symptom. 

Dilatation  of  the  Stomach. — In  this  condition  the  food  does  not 
pass  readily  into  the  intestine,  but  remains  in  the  stomach  and  under- 
goes changes  which  produce  sufficient  irritation  to  cause  vomiting. 

Pyloric  Stenosis. — In  pyloric  stenosis  the  food  is  prevented  by 
the  narrow  pyloric  opening  from  passing  into  the  intestine,  one  feed- 
ing follows  another,  the  stomach  becomes  overloaded,  and,  by  reason 
of  fermentative  change  in  the  residue,  sufficient  irritation  is  produced, 
in  connection  with  the  spasmodic  contractions  of  the  stomach  peculiar 
to  the  condition,  to  induce  vomiting. 

Causes  Remote  from  the  Stomach. — In  intestinal  obstruction, 
whether  due  to  intussusception,  volvulus,  peritonitis,  or  impacted 
feces,  vomiting  is  an  invariable  accompaniment,  continuing  at  irregu- 
lar intervals  until  the  obstruction  is  relieved  or  until  the  child  dies. 

The  exanthemata  and  lobar  pneumonia  are  very  commonly  ushered 
in  by  vomiting  if  the  onset  is  sudden  and  intense.  In  appendicitis 
in  children,  vomiting  is  usually  one  of  the  early  symptoms;  so  also,  in 
the  diflFerent  forms  of  meningitis,  vomiting  is  often  an  early  symptom, 
and  may  continue  persistently  during  the  first  few  days  of  the  illness. 
In  nephritis,  with  uremia,  vomiting  is  usually  present.  Vomiting  may 
be  caused  by  fright,  by  shock,  or  by  a  strain  of  any  nature,  as  in  whoop- 
ing-cough, or  it  may  be  of  purely  nervous  origin. 

Illustrative  Case. — A  few  years  ago  I  had  a  most  unusual  and  interesting  case. 
The  patient  was  a  girl  four  years  old,  pale  and  thin.  The  history  was  that  of 
vomiting  for  more  than  a  year,  which  had  begun  with  rather  a  protracted,  badly 
managed  attack  of  indigestion.  At  first  there  were  but  one  or  two  attacks  a  day. 
Later  they  became  more  frequent,  and  for  a  few  weeks  before  the  child  came  to 
me  the  vomiting  had  occurred  at  the  table  with  nearly  every  meal,  before  the  meal 
was  completed.  The  mother  was  most  anxious  and  apprehensive  regarding  the 
child's  condition.  The  former  was  always  with  the  patient,  always  fed  her,  and 
always  worried  constantly  throughout  the  meal,  fearing  an  attack  of  vomiting. 
Using  the  most  thorough  means  of  examination  of  the  stomach,  I  failed  to  find 
anything  wrong  with  it.  After  some  days'  observation  it  occurred  to  me  that  the 
presence  of  the  apprehensive  mother,  in  whose  mind  the  condition  of  the  child  and 
the  vomiting  were  uppermost,  might  be  a  factor  in  causing  the  vomiting.  _  I 
accordingly  directed  that  the  child  take  her  meals  in  the  kitchen  with  the  maid, 


220  THE    PRACTICE    OF    PEDIATRICS 

and  that  the  matter  of  vomiting  should  not  be  mentioned.  The  mother  was 
directed  not  to  come  in  contact  with  the  child  in  any  way  during  the  meal.  I  was 
much  gratified  and  not  a  little  surprised  when  the  vomiting  promptly  ceased. 
After  a  few  months  of  this  regime  the  maid  was  taken  ill,  and  the  mother  for  one 
day  attended  to  the  feeding.     Again  the  child  vomited  as  before. 

The  management  of  the  different  types  of  vomiting  will  be 
referred  to  in  the  consideration  of  the  various  diseases  with  which  it  is 
associated. 

RUMINATION 

Rumination  is  a  rather  infrequent  condition  and  one  which  is  likely 
to  be  overlooked  unless  one  is  very  careful  to  watch  the  vomiting  child 
after  feedings.  It  is  characterized  by  the  regurgitation  of  food  after 
almost  every  feeding,  part  of  which  is  actually  vomited  and  the  rest  is 
re-swallowed. 

Etiology. — This  condition  occurs  most  frequently  in  children  a  few 
months  of  age  and  is  often  not  diagnosed  until  the  vomiting  has  been 
going  on  for  several  weeks.  The  condition  may  also  be  present  in 
older  children.  When  practised  at  this  age  it  has  become  a  habit  and 
occurs  especially  in  the  neurotic.  In  infants  there  may  be  an  asso- 
ciated pylorospasm. 

Symptoms.— The  clinical  picture  is  fairly  characteristic,  closely 
resembling  that  of  the  ruminating  animals,  such  as  the  "cow  chewing 
the  cud."  A  few  minutes  after  the  baby  gets  its  bottle,  it  will  start 
peculiar  suction  movements  and  presently  some  of  the  milk  can  be 
seen  in  the  mouth,  a  part  may  spill  out  and  part  will  be  chewed  and 
re-swallowed.  This  proceeding  will  be  repeated  until  the  child  has 
emptied  its  stomach  or  fallen  asleep. 

These  children  are  often  much  emaciated  from  the  prolonged  loss 
of  food. 

Treatment. — A  popular  method  of  treatment  is  to  give  food  so 
thick  that  it  cannot  readily  be  regurgitated.  A  mixture  containing 
\y'2  ounces  of  barley  flour  to  1  pint  of  skimmed  milk  is  cooked  in  a 
double  boiler  for  one  hour.  On  cooling,  this  forms  a  thick  gelatinous 
mass.  It  is  fed  with  a  spoon  to  the  child  in  quantities  to  which  he 
is  accustomed  at  intervals  of  3  to  4  hours. 

Strauch,  of  Chicago,  has  observed  that  the  nostrils  had  to  be 
open  to  aid  the  child  in  regurgitating  the  food.  He  therefore  im- 
provised a  clamp  to  keep  them  closed  for  a  certain  time  after  feedings. 
In  this  way  he  controlled  the  vomiting  to  a  great  extent. 

In  a  private  patient  the  habit  was  broken  by  substituting  another 
habit,  less  harmful.  The  ruminating  infant  was  taught  to  use  the 
pacifier.  Sucking  the  pacifier  proved  more  entertaining  than 
ruminating. 

Sedgwick  advises  strapping  the  lower  jaw  firmly  to  the  upper  by 
means  of  adhesive  plaster,  thereby  preventing  the  rhythmical  jaw 
action  necessary  for  regurgitation. 

ACUTE  ILEOCOLITIS  (DYSENTERY) 

In  dysentery  there  is  a  well-defined  infection  of  the  intestine.  In 
common  with  other  intestinal  disorders  it  occurs  most  frequently  dur- 


ACUTE    ILEOCOLITIS    (dYSENTERY)  221 

ing  the  hot  months.  The  later  summer  and  early  autumn  supply  the 
most  cases.  In  hke  manner  it  often  follows  the  milder  gastro-intestinal 
derangements  which  are  productive  of  reduced  vitality  and  diminished 
intestinal  resistance. 

Bacteriology. — In  a  large  percentage  of  cases  of  infantile  diarrhea 
associated  with  blood  and  mucus  in  the  stools  the  dysentery  bacillus 
is  present.  It  may  be  found  in  large  numbers,  sometimes  in  almost 
pure  cultures.  Duval  and  Bassett,  in  1902,  were  the  first  to  find 
Bacillus  dysenteriae  in  the  stools  of  cases  of  infantile  summer  diarrhea. 
The  type  of  the  bacillus  which  does  not  ferment  mannite  (the  Shiga 
type)  is  not  found  so  often  in  these  cases  as  are  the  two  mannite-fer- 
menting  types :  the  Flexner-Manilla  and  the  Hiss-Russel,  of  which  the 
former  ferments  maltose,  saccharose,  and  dextrin,  and  the  latter  does 
not. 

The  presence  of  agglutinins  in  the  blood  of  the  patient  is  evidence 
of  the  causal  relationship  of  Bacillus  dysenteriae  to  the  existing  disease. 
The  agglutinins  are  not  present,  as  a  rule,  until  the  second  week  of  the 
disease. 

Pathology. — The  lower  portion  of  the  ileum — rarely  more  than 
three  feet — and  the  colon  are  the  locations  of  the  lesion  which  may 
show  a  wide  variation  in  intensity,  depending  on  the  character  of  the 
infecting  organism  and  the  resistance  of  the  patient.  While  the  major 
lesions  are  usually  in  the  colon,  the  small  intestine  will  show  pathologic 
changes  in  at  least  35  per  cent,  of  the  cases.  There  may  be  localized 
areas  of  congestion  through  the  intestine,  enlargement  of  the  solitary 
follicles,  and  swelling  of  Beyer's  patches.  In  nearly  all  cases,  whether 
the  lesions  are  mild  or  severe,  there  will  be  moderate  swelling  and  con- 
gestion of  the  mesenteric  glands. 

The  inflammation  may  be  acute  or  chronic,  and  catarrhal,  ulcera- 
tive, or  pseudomembranous  in  type.  Although  the  term,  dysentery 
is  properly  used  to  denote  only  infections  by  the  bacilli  of  Shiga  and 
Flexner  and  the  special  protozoon,  Amoeba  coli,  the  lesions  produced 
may  be  conveniently  considered  under  the  term,  ileocolitis. 

In  a  series  of  82  autopsies  upon  cases  of  ileocolitis  Holt  found  fol- 
licular ulceration  predominant  in  36,  catarrhal  inflammation  in  26, 
membranous  inflammation  in  14,  and  catarrhal  inflammation  with 
superficial  ulceration  in  6.  Of  412  cases  studied  by  Holt  and  Flexner 
in  1903,  270  showed  the  presence  of  Bacillus  dysenteriae,  and  Flexner 
acid-forming  type  of  organism  appearing  most  frequently.  Strains 
intermediate  between  the  Shiga  and  Flexner  bacilli  are  occasionally 
found,  and  in  the  causation  of  a  certain  proportion  of  cases  of  epidemic 
dysentery  Bacillus  pyocyaneus  has  been  shown  to  be  active.  Amebic 
dysentery  is  common  only  in  tropical  or  subtropical  regions. 

In  simple  ileocolitis  of  the  mild  catarrhal  form  the  submucosa  is  but 
slightly  involved.  The  mucosa,  however,  is  swollen,  congested,  and 
covered  with  secretion,  and  dotted  with  occasional  points  of  hemor- 
rhage and  spots  of  epithelial  exfoliation.  The  lymph-follicles  are 
swollen  and  hypertrophied,  and  the  adjacent  connective  tissue  is  in- 


222  THE    PRACTICE    OF    PEDIATRICS 

filtrated  with  round-cells.  Microscopically,  this  infiltration  is  also 
apparent  about  the  vessels  in  the  submucosa.  The  stools  are  ordi- 
narily green  and  thin  in  consistence,  and  contain  mucus,  desquamated 
epithehum,  and  traces  of  blood.  In  severe  cases  the  inflammation 
acquires  the  ulcerative  or  membranous  character,  the  lymphoid  follicles 
are  elevated  and  superficially  necrotic,  and  the  submucosa  is  infiltrated 
with  pus.  In  such  instances  the  ulcerations  extend  deeply,  and  ex- 
ceptionally involve  the  entire  intestinal  wall. 

The  Ulcerative  Forin. — In  ulcerative  ileocolitis  the  ulcers  may  origi- 
nate in  the  solitary  follicles,  and  are  then  small,  superficial,  round, 
yellow,  sharply  defined,  and  surrounded  by  an  inflammatory  zone. 
Later  the  ulcers  may  grow  larger,  coalesce,  and  become  deeper,  exposing 
the  submucosa  or  even  the  muscularis.  Ulcers  may  also  originate  in 
the  mucosa  itself  and  not  in  the  follicles;  this  may  occur  in  dysentery 
or  in  cases  of  severe  catarrhal  inflammation.  As  a  consequence  of 
the  coalescence  of  these  ulcers  the  mucosa  has  a  ragged  appearance, 
with  islands  of  gray  or  congested  mucous  membrane  visible  between 
the  irregularly  shaped  ulcers  of  all  sizes.  Small  ulcers  heal  completely, 
but  large  ones  rarely  do.  Stenoses  as  the  result  of  cicatrization  of  these 
ulcers  do  not  occur  in  children.  In  cases  of  long  standing  all  the  in- 
testinal coats  are  thickened,  due  to  inflammatory  infiltration,  and  the 
mucosa  becomes  pigmented. 

In  'pseudomembranous  ileocolitis  the  intestinal  mucosa  is  covered 
with  a  fibrinous  exudate,  which  can  be  rubbed  off  at  first,  but  later  is 
very  adherent.  The  mucosa  becomes  necrotic,  and  larger  or  smaller 
areas  are  lost,  leaving  a  congested,  edematous  base,  surrounded  by 
necrotic  tissue.  The  pseudomembrane  becomes  colored  yellow  or 
greenish  by  the  feces.  The  wall  as  a  whole  is  thickened.  The  lesion  is 
usually  most  marked  in  the  colon,  but  the  lower  ileum  is  often  involved 
as  well.     Healing  may  occur,  but  is  rare;  death  is  the  rule. 

Associated  Lesions. — In  severe  cases  of  ileocolitis  the  mesenteric 
lymph-glands  are  involved  and  the  spleen  may  be  enlarged.  Perfora- 
tion of  the  bowel,  abscess  of  the  liver,  nephritis,  and  broncho-pneu- 
monia are  occasional  complications. 

Symptoms. — A  great  deal  of  confusion  has  been  occasioned  by 
attempts  at  a  nomenclature  of  the  acute  inflammatory  diseases  of  the 
intestine  which  shall  make  the  clinical  aspect  of  the  cases  fit  the  patho- 
logic findings.  Differentiation,  antemortem,  into  catarrhal,  follicular, 
and  ulcerative  types  is  impossible,  as  has  been  proved  by  the  care  and 
daily  observation  in  institution  and  hospital  work  of  cases  that  have 
later  come  to  autopsy. 

Consider  briefly,  for  illustration,  the  gravest  cases — cases  which 
at  autopsy  show  most  extensive  ulceration  of  the  intestine.  In  many 
of  these  there  has  been  a  low  temperature, — from  100°F.  to  102°F., — 
and  the  stools  have  never  contained  a  particle  of  blood.  In  others  in 
which  perhaps  considerable  blood  has  been  passed  for  several  days, 
there  is  but  a  mild  congestion  of  the  mucous  membrane  of  the  large 
intestine.     In  still  other  cases  which  continue  for  a  considerable  time, 


ACUTE    ILEOCOLITIS    (dYSENTERY)  223 

— from  two  to  three  weeks, — with  moderate  temperature,  death 
results  from  exhaustion,  and  autopsy  shows  nothing  but  an  enlarge- 
ment of  the  solitary  follicles,  with  areas  of  congestion  in  the  lower  por- 
tion of  the  small  intestine. 

Acute  ileocolitis  may  be  the  primary  intestinal  disease.  In  this 
condition  the  temperature  is  usually  considerably  elevated  at  the 
commencement  of  the  illness — 103°  to  104°F.  After  an  evacuation 
of  two  or  three  undigested  stools  the  passages  consist  of  light-colored 
mucus,  often  streaked  with  blood,  or  they  are  of  green  mucus  and 
streaked  with  blood.  In  some  cases  there  is  a  considerable  hemorrhage. 
Relaxation  of  the  sphincter  and  prolapse  of  the  rectum  are  not  at  all 
unusual.  The  passages  are  small,  frequent,  and  attended  with  con- 
siderable pain  and  tenesmus.  I  have  repeatedly  seen  from  20  to  30 
such  passages  from  one  patient  in  twenty-four  hours. 

Far  more  frequently,  however,  this  condition  follows  acute  gastro- 
enteric indigestion  or  an  intestinal  infection,  the  dangers  of  which  have 
not  been  appreciated,  and  which,  in  consequence  has  been  improperly 
treated.  The  lesions  produced  are  due  to  the  bacteria  and  their  toxins, 
which  have  abundant  opportunity  to  produce  pathological  changes  in 
the  intestinal  mucous  membrane,  the  extent  of  which  can  only  be  con- 
jectured during  life. 

An  important  feature  of  some  of  these  cases  is  that  an  extreme 
degree  of  toxemia,  with  resulting  prostration,  may  be  present,  with 
little  fever  and  insignificant  bowel  symptoms.  In  other  cases  the 
bowel  manifestations  are  very  active  and  the  toxemia  is  slight.  The 
active  cases  offer  the  better  prognosis.  Vomiting  may  be  present  at  the 
onset  of  the  attack,  but  is  not  usually  a  symptom  of  consequence. 
There  is  always  emaciation.  The  degree  of  prostration  is  dependent 
upon  the  amount  of  toxemia,  the  extent  of  the  lesion,  and  the  manage- 
ment of  the  case,  particularly  as  relates  to  supportive  measures  and 
the  nature  of  the  nutrition. 

Duration. — The  duration  of  an  ileocolitis  is  longer  than  that  of  any 
of  the  intestinal  disorders  previously  mentioned.  With  the  disease 
established  it  is  rare  for  a  case  to  recover  under  ten  days.  The  duration 
of  the  illness  is  often  two  or  three  weeks.  I  have  repeatedly  known 
cases  to  continue  over  four  weeks.  In  fact,  the  duration  in  many  in- 
stances is  similar  to  that  of  typhoid  fever.  The  temperature  range  is 
variable — from  normal  to  104°F.  For  three  or  four  weeks  in  a  given 
case  there  may  be  a  low  temperature  range — 99.5°  to  101.5°  or  102°F. 

Treatment. — Recent  work  in  the  bacteriology  of  the  acute  intestinal 
diseases  has  added  nothing  to  our  knowledge  as  to  the  treatment  of  the 
condition,  and  consequently  does  not  call  for  discussion  here.  Milk 
is  to  be  stopped  at  once,  whether  the  patient  is  breast-fed  or  bottle-fed. 
Barley-water,  granum-water,  or  rice-water  No.  1  (see  formulary,  p. 
70)  constitutes  the  basis  of  diet  for  children  under  one  year  of  age. 
Older  children  may  be  given  the  No.  2  mixture.  To  these  carbo- 
hydrate foods  may  be  added  an  ounce  of  chicken  or  mutton  broth,  with 
salt  or  sugar  to  make  them  more  palatable.     It  is  well,  for  variety,  to 


224  THE    PRACTICE    OF    PEDIATRICS 

make  up  two  or  three  cereal  preparations  and  alternate  their  use.  In 
this  way  the  foods  will  be  better  taken  and  for  longer  periods  than  if 
but  one  is  prepared.  In  this  form  of  substitute  feeding  an  amount 
similar  to  what  the  child  was  accustomed  to  in  health  may  be  given, 
but  the  intervals  may  be  shorter  by  one-half  hour  or  one  hour. 

To  patients  of  any  age  Eiweiss  Milch  (page  65),  two  or  three 
feedings  daily,  may  be  given.  It  supplies  additional  nutrition,  and  if 
the  disease  is  prolonged,  there  is  correspondingly  less  emaciation.  In 
using  the  Eiweiss  Milch  it  should  at  first  be  diluted  with  barley- 
water — ^'i  milk  to  %  water  at  first,  to  be  increased  to  ^^  milk  and  3^ 
barley-water. 

Drugs. — I  have  had  abundant  opportunity  to  test  the  value  of  the 
different  drugs  advocated  from  time  to  time  for  the  treatment  of  this 
disease.  Drugs  which  have  proved  of  unquestioned  value  are  castor 
oil,  subnitrate  of  bismuth,  and  opium.  Drugs  which  have  an  occa- 
sional application  are  sulphur  and  the  preparations  of  tannin.  Con- 
stitutional measures,  supportive  in  character,  such  as  heat  and  stimu- 
lation, are,  of  course,  used  when  indicated,  as  in  any  severe  exhaustive 
illness. 

At  the  commencement  of  the  attack  two  drams  of  castor  oil  should 
be  given.  If  this  is  not  retained,  from  one  to  two  grains  of  calomel 
should  be  given  in  divided  doses — 3^  grain  every  hour.  In  cases  with 
considerable  fever  and  infrequent  stools  it  is  well  to  repeat  the  oil  or 
give  some  other  laxative,  such  as  magnesia,  every  two  or  three  days. 

Bismuth  subnitrate  is  best  given  in  10-grain  doses,  according  to  the 
suggestions  on  p.  198.  If  black  stools  do  not  follow  its  administration, 
one  grain  of  precipitated  sulphur  is  added  to  each  dose.  To  be  effective, 
the  bismuth  must  be  given  in  large  doses.  Two  or  three  grains  at 
intervals  of  two  or  three  hours  are  of  no  value.  In  cases  over  one  year 
of  age  15  to  20  grains  are  frequently  given  at  two-hour  intervals.  I 
have  used  hundreds  of  pounds  of  bismuth  in  children  during  the  past 
twenty-five  years,  and  have  yet  to  see  harm  resulting  from  its  use.  Of 
course,  the  physician  must  use  a  pure  article.  Not  a  few  cases  do 
admirably  under  the  cereal-water  diet,  castor  oil,  bismuth,  and  sulphur. 
Tannalbin,  in  doses  of  2  grains  in  infants,  and  from  5  to  8  grains  in 
older  children,  is  sometimes  of  service  when  there  is  a  tendency  to  large 
watery  stools  or  stools  containing  large  quantities  of  mucus.  This 
also  may  be  given  at  the  same  time  as  the  bismuth. 

When  there  is  much  pain  and  tenesmus,  with  frequent,  scanty, 
mucous  stools,  opium  may  be  used  with  advantage,  with  a  view  to  con- 
trolling the  tenesmus  and  diminishing  the  frequency  of  the  stools. 
Paregoric  or  Dover's  powder  is  usually  selected  for  this  purpose. 
Dover's  powder  is  preferred,  because  of  the  absence  of  a  disagreeable 
taste  and  the  convenience  of  its  administration.  It  may  be  added  to 
the  bismuth  at  each  dose,  not  combined  with  it  in  a  prescription,  for 
uncombined  it  may  be  at  once  discontinued  or  given  in  smaller  doses 
with  a  diminution  in  the  number  of  the  stools. 

Careful  instructions  should  be  given  when  prescribing  opium.     It 


ACUTE    ILEOCOLITIS    (dTSENTERt)  225 

is  to  be  given  for  a  definite  purpose — to  prevent  straining  and  the  fre- 
quent passages  due  to  excessive  peristalsis.  As  in  the  treatment  of 
acute  intestinal  infection,  particularly  if  there  is  temperature,  it  is  not 
well  to  attempt  to  reduce  the  number  of  the  stools  below  four  or  five  in 
twenty-four  hours,  and,  of  course,  opium  is  not  to  be  given  at  all  unless 
the  stools  are  very  frequent.  The  amount  of  opium  that  will  be  required 
in  a  given  case  may  readily  be  determined  by  carefully  watching  the 
character  and  frequency  of  the  stools.  For  children  under  one  year  of 
age  the  dosage  of  Dover's  powder  is  from  3^8  to  \i  grain  at  two-hour 
intervals,  not  more  than  7  doses  being  given  in  twenty-four  hours. 
From  the  first  to  the  tenth  year  the  dose  ranges  from  3^^  grain  to  2 
grains.  Mothers  and  nurses  should  be  instructed  that  when  there  is  a 
rise  in  the  temperature,  or  when  the  child  becomes  drowsy  after  its 
use,  the  opium  is  to  be  discontinued,  or  the  dose  reduced  one-half— 
another  advantage  of  giving  it  independently.  The  younger  the  child, 
the  greater  caution  to  be  observed  in  its  use. 

When  heart  stimulants  are  necessary,  the  tincture  of  strophanthus 
is  usually  selected.  Digitalis  is  not  well  borne  by  the  stomach;  and  for 
the  same  reason,  as  well  as  because  of  its  unfavorable  effect  upon  the 
kidneys,  alcohol  should  be  given  with  caution.  When  used,  alcohol 
should  be  well  diluted  and  given  only  temporarily — during  the  urgent 
period  of  acute  toxemia.  Its  prolonged  use  invariably  interferes  with 
the  stomach  function. 

Caffein  sodium  salicylate,  in  3^^-  to  1-grain  doses  at  two-hour  inter- 
vals, and  atropin,  3-1000  to  3^600  grain  at  four-hour  intervals,  are  par- 
ticularly useful  in  the  asthenic  cases.  For  threatened  collapse  cam- 
phor, 1  to  2  grains  hypodermatically  in  oil,  answers  well  but  requires 
frequent  repetition  at  one-  to  two-hour  intervals.  Adrenalin  1 :  1000 
in  2  to  5  drop  doses,  by  stomach  or  hypodermatically,  is  also  of  much 
service  in  collapse. 

Hot  Applications. — Hot  stupes  or  hot  compresses  to  the  abdomen 
are  often  most  grateful  to  the  patient  when  there  is  abdominal  pain 
and  tenesmus.  The  hot  applications  should  be  changed  every  fifteen 
or  twenty  minutes,  never  being  allowed  to  become  cold. 

Colon  irrigation  should  be  used  at  least  once  in  every  case  of  colitis, 
normal  salt  solution  being  employed  at  100°  to  105°F.  The  solution 
should  always  be  used  warm,  as  it  has  a  pronounced  sedative  effect  in 
some  patients  when  used  in  this  way,  and  thus  may  fulfil  two  purposes. 
Whether  the  irrigation  is  repeated  or  not  must  depend  upon  its  effect 
upon  the  patient.  When  he  strains  against  it  and  there  is  no  apparent 
diminution  in  the  number  of  the  stools,  it  should  not  be  repeated. 
Frequently,  however,  the  intestine  remains  quiet  and  the  number  of 
passages  is  diminished  after  a  warm  irrigation — 105°  to  110°F.  In 
such  cases  it  may  be  repeated  twice  daily.  In  cases  in  which  there  is 
not  an  active  bowel  action,  and  decomposing  blood  and  mucus  are  re- 
moved by  the  washing,  it  may  be  used  once  or  twice  daily. 

Only  in  the  rarest  instances,  when  there  is  high  fever  and  bowel 
action  is  delayed,  should  intestinal  irrigation  be  practised  oftener  than 
15 


226  THE    PRACTICE    OF    PEDIATRICS 

once  in  twelve  hours.  This  Hne  of  treatment  is  often  overdone.  Irri- 
gation should  always  be  used  for  a  definite  purpose,  and  discontinued 
when  that  purpose  is  accomplished.  Every  year,  at  the  close  of  the 
heated  term,  I  see  cases  of  chronic  colitis  without  fever  which  are  being 
treated  by  irrigations  two  or  three  times  daily  without  any  indication 
for  the  irrigation  other  than  the  mucous  stools.  Irrigations,  without 
question,  help  to  keep  up  the  secretion  of  mucus,  for  I  have  repeatedly 
seen  it  disappear  entirely  in  a  few  days  without  other  treatment  after 
the  discontinuance  of  the  irrigation.  When  irrigation  is  practised  fre- 
quently in  those  with  inactive  peristalsis,  it  is  possible  to  produce  a 
general  edema  due  to  the  absorption  of  the  fluid.  This  has  been  done 
experimentally  in  well  children. 

Starch  and  Opium. — The  time-honored  remedy — the  injection  of 
starch  and  opium — may  be  of  service  in  the  cases  in  which  there  is 
much  tenesmus,  with  the  passage  of  small  amounts  of  blood-streaked 
mucus  or  the  discharge  of  bloody  mucus  from  the  rectum.  In  these 
cases  the  principal  lesions  are  usually  located  in  the  sigmoid  and 
rectum.  A  straight-pipe,  hard-rubber  syringe  answers  best  for  this 
purpose.  A  starch  solution  of  the  strength  of  1  dram  of  starch  to  1 
ounce  of.  boiled  water  is  used.  For  infants  under  one  year  of  age  5 
drops  of  laudanum  may  be  added  to  2  ounces  of  the  starch  solution, 
and  repeated  at  intervals  of  six  to  eight  hours.  Older  children  may  be 
given  from  8  to  12  drops  of  laudanum  with  4  ounces  of  the  starch 
solution;  this  may  be  repeated  in  four  to  six  hours. 

Improvement  in  the  colitis  is  indicated  by  a  subsidence  of  the 
temperature,  a  change  in  the  character  of  the  stools  from  green  or  clear 
mucus,  with  blood  and  scarcely  any  odor,  to  passages  which  gradually 
take  on  a  fecal  odor  and  show  the  presence  of  feces  mixed  with  mucus. 

The  Influence  of  Climate. — When  the  case  is  under  control,  a  change 
of  climate  is  most  beneficial.  A  child  who  has  had  colitis  at  the  sea- 
shore or  in  town  will  invariably  have  recovery  hastened  by  a  removal 
inland  to  the  mountains  or  among  the  hills,  where  an  open-air  life  is 
to  be  insisted  upon. 

Diet  in  Convalescence. — With  a  subsidence  of  the  fever  and  an  im- 
provement in  the  number  and  character  of  the  stools  the  patient's 
troubles  are  not  over.  The  problem  of  nutrition  is  often  a  difficult 
one.  The  child  has  necessarily  been  on  a  reduced  diet  for  several  days 
— often  for  two  to  three  weeks.  If  better  nutrition  than  cereal  gruels 
and  Eiweiss  Milch  is  not  soon  forthcoming,  the  patient  faces  the  danger 
of  malnutrition  and  marasmus,  which  is  the  outcome  in  not  a  few  of 
the  badly  treated  cases  in  which  the  disease  is  not  quickly  fatal.  The 
use  of  fresh  milk  must  sooner  or  later  be  attempted. 

In  all  these  cases  the  child  has  not  been  getting  sufficient  caloric 
units  for  maintenance  of  weight.  This  applies  particularly  to  children, 
who,  on  account  of  age  or  refusal  to  take  it  or  intolerance,  have  not  had 
the  benefits  of  Eiweiss  Milch. 

Children  who  have  had  colitis  bear  fat  badly.  The  younger  the 
child,  the  more  certainly  is  this  the  case.     This  has  been  so  forcibly 


CHRONIC    ILEOCOLITIS  227 

impressed  upon  me  that  I  have  discontinued  attempts  at  feeding  these 
convalescents,  even  with  small  quantities  of  whole  milk.  I  have  found 
that  they  do  best  on  a  carbohydrate  gruel  as  a  basis  of  diet,  to  which 
sugar-of-milk  is  added  in  the  proportion  of  from  i-^  to  1  ounce  to  the 
pint,  thereby  furnishing  material  for  heat  and  energy.  To  this  sugar- 
cereal  combination,  boiled  skimmed  milk  in  small  quantities  is  added, 
not  over  3=-^  ounce,  and  that  to  only  one  of  the  feedings,  the  first  day  that 
milk  is  given.  If  this  causes  no  inconvenience,  an  increase  of  ^^  ounce 
is  made  at  every  second  feeding  the  following  day,  and  an  increase  of 
3^^  ounce  at  every  feeding  the  third  day.  The  total  quantity  of  food 
given  at  each  feeding  is  to  remain  the  same,  an  equal  quantity  of  the 
cereal  diluent  being  removed  to  make  way  for  the  milk  increase. 
Thereafter,  if  all  goes  well,  an  increase  of  3^  ounce  is  made  in  each 
feeding  every  day  until  the  child  is  taking  his  daily  feedings  of  skimnied 
milk  one-half  strength.  In  some  cases  it  may  be  found  that  the  child 's 
capacity  will  be  only  2  ounces  of  skimmed  milk  at  a  feeding  with  the 
cereal-water  diluent.  Here  he  must  be  held,  perhaps,  for  a  week  or 
two  before  milk  can  safely  be  advanced.  Usually  the  younger  the 
child,  the  more  difficult  will  be  the  resumption  of  the  milk  diet.  After 
the  first  year  the  nutrition  may  be  assisted  by  a  thick  gruel,  such  as 
No.  2  (see  formulary,  p.  70),  zwieback,  bread-crusts,  or  rare  scraped 
beef — two  or  three  teaspoonfuls  daily,  with  a  couple  of  feedings  of 
Eiweiss  Milch  or  buttermilk.  By  infants  under  one  year  of  age  who 
cannot  take  even  a  weak  dilution  of  skimmed  milk,  granum  No.  1 
(p.  70)  will  usually  be  well  taken.  If  there  is  abdominal  distention 
from  starch  indigestion,  the  granum  may  be  dextrinized.  Barley- 
water  also  answers  well  as  a  diluent  for  evaporated  milk.  In  adding 
evaporated  milk  to  the  cereal  water  sugar  is  to  be  omitted.  The  evapo- 
rated milk  may  be  increased  slowly  until  from  1  to  4  drams  are  given 
at  a  feeding.  Under  no  ordinary  considerations,  however,  should 
this  diet  be  permanent.  After  from  two  to  four  weeks  the  use  of 
plain  milk  should  be  attempted,  replacing  one  feeding  of  the  evapo- 
rated by  a  small  amount  of  plain  milk — 3^^  to  1  ounce  is  the  customary 
diluent. 

Obstinate  constipation  sometimes  follows  recovery  from  severe 
ileocolitis.  This  is  to  be  managed  along  the  lines  laid  down  for  the 
management  of  constipation  (p.  244).  Following  an  attack  of  ileoco- 
litis the  patient  must  never  be  allowed  to  pass  twenty-four  hours 
without  an  evacuation  of  the  bowels.  A  standing  order  should  be 
given  that  an  enema  should  be  used  when  this  does  not  occur. 

CHRONIC  ILEOCOLITIS 

Cases  of  chronic  ileocolitis  coming  under  my  care  have  invariably 
been  preceded  by  acute  attacks  that  were  unusually  severe  or  that  were 
badly  managed.  These  cases  represent  one  of  the  forms  of  malnutri- 
tion, but  are  of  such  a  nature  as  to  require  special  consideration. 

The  walls  of  the  intestines  are  thickened  with  connective-tissue  for- 


228  THE    PRACTICE    OF    PEDIATRICS 

mation,  and  the  solitary  follicles  have  undergone  pigmentation  as  a 
result  of  hemorrhages  or  congestion. 

.  Symptoms. — The  patient  is  emaciated,  and  often  three  or  four 
pounds  under  weight;  the  skin  is  dry  and  rough;  the  circulation  is  poor; 
the  extremities  are  cold,  and  the  temperature  is  often  subnormal,  show- 
ing an  occasional  sharp  rise.  The  abdomen  is  always  distended  with 
gas.  The  stools  usually  are  loose,  number  three  or  four  daily,  and  con- 
tain mucus  in  considerable  amount.  The  mucus  may  be  absent  for 
two  or  three  days;  then  there  will  be  a  rise  in  temperature  of  from 
102°F.  to  105°F.,  and  large  quantities  will  be  passed  with  a  very  foul 
odor.  The  nervous  symptoms  are  usually  marked.  The  child  is 
irritable  and  sleeps  poorly.  He  cries  a  great  deal,  is  very  unhappy, 
and  looks  as  wretched  as  he  apparently  feels. 

In  assuming  the  care  of  one  of  these  cases  it  is  well  to  inform  the 
parents  that  a  rapid  improvement  is  not  to  be  looked  for.  A  patient 
aged  three  and  one-half  years,  who  eventually  recovered,  weighed  but 
23  pounds — 2  pounds  less  than  when  she  was  eighteen  months  old. 
During  the  first  six  months  that  I  treated  her  there  was  very  slow  im- 
provement in  spite  of  every  advantage  that  care  and  change  of  climate 
could  afford. 

Treatment. — The  management  consists  in  a  proper  diet,  change  of 
climate  when  possible,  and  supportive  measures.  It  is  for  the  physician 
to  find  out  in  a  given  case  what  means  of  nutrition  are  best.  These 
cases  vary  considerably  in  their  digestive  possibilities,  with  the  excep- 
tion that  they  all  bear  fat  foods  badly. 

Diet. — Chronic  colitis  is  very  fatal  in  young  infants,  and  but  few 
survive.  By  far  the  best  food  for  infants  under  one  year  of  age  is 
breast-milk,  which  at  first  must  be  given  in  small  quantities.  Sugar- 
water  should  be  given  before  the  nursing.  These  young  infants  do  not 
do  well  on  starchy  foods  unless  they  have  been  dextrinized  (p.  71) ; 
when  predigested,  they  may  have  too  laxative  an  effect,  and  should 
be  given  in  small  quantities.  The  use  of  starch,  therefore,  in  these 
cases,  for  a  considerable  time  at  least,  is  limited. 

Eiweiss  Milch  and  buttermilk  have  failed  me  absolutely  in  feeding 
these  young  children.  The  patient  may  be  able  to  digest  the  unsweet- 
ened condensed  milk  in  the  proportion  of  1:6  or  12  of  water  or  weak 
gruel  diluents.  Two  or  three  feedings  a  day  may  be  given  in  alterna- 
tion with  a  dextrinized  gruel.  The  addition  of  3^^  ounce  of  gelatin  to 
the  pint  of  food  makes  a  desirable  addition  to  the  feeding  of  malnutri- 
tion cases  in  which  food  of  low  caloric  value  is  necessary. 

The  beaten  white  of  egg  may  be  given  in  diluted  skimmed  milk  or 
in  dextrinized  gruel  No.  3  (p.  70)  if  it  agrees,  or  in  plain  water  with  salt 
added.  The  whites  of  two  or  three  eggs  may  thus  be  given  daily 
with  benefit.  For  older  children,  after  the  first  year,  skimmed  milk, 
Eiweiss  Milch,  rare  scraped  meat,  junket,  and  coddled  white  of  egg 
or  raw  egg  are  usually  best.  Zwieback  or  bread-crusts  may  be  given  in 
small  quantities.  Alcohol,  if  given  at  all,  should  not  be  long  continued. 
I  usually  feed  these  patients  five  times  a  day,  at  four-hour  intervals. 


MUCOUS    COLITIS  229 

There  should  be  a  standing  order  for  an  enema  after  an  interval 
of  twenty-four  hours  if  no  movement  from  the  bowel  takes  place  dur- 
ing that  time.  Absence  of  bowel  movement  in  these  cases  almost  in- 
variably is  followed  b}^  fever,  prostration,  and  perhaps  convulsions. 
If  there  is  a  tendency  to  constipation,  as  there  will  be  in  some  cases, 
some  laxative,  such  as  magnesia  or  the  aromatic  fluidextract  of  cascara, 
should  be  given  daily  in  sufficient  amount  to  insure  at  least  one  free 
evacuation. 

Irrigation  of  the  colon  is  not  be  to  used  as  a  routine  measure.  It  is 
indicated  whenever  there  is  a  rise  in  temperature,  even  though  the 
bowels  have  moved  but  a  few  hours  previously.  A  laxative,  prefer- 
ably castor  oil  or  calomel,  should  also  be  given. 

The  further  treatment  calls  for  salt  baths,  oil  inunctions,  and  the 
open-air  life  referred  to  in  the  section  on  Malnutrition,  p.  92. 

MUCOUS  COLITIS 

Mucous  colitis  is  a  chronic  catarrhal  condition  of  the  colon,  char- 
acterized by  the  production  of  very  large  quantities  of  mucus.  The 
mucus  forms  a  pseudomembrane  over  the  mucosa,  and  is  passed  in 
the  form  of  casts  or  large,  worm-like  masses. 

Attention  has  elsewhere  been  called  to  the  necessity,  in  dealing  with 
some  of  the  diseases  of  children,  of  ignoring  what  appears  to  be  a  local 
manifestation  of  disease,  and  treating  the  patient  along  dietetic  and 
hygienic  lines.  This  necessity  is  in  no  instance  better  illustrated  than 
in  mucous  colitis,  a  disease  fortunately  rare  in  children,  yet  of  sufficient 
frequency  to  warrant  our  attention. 

Etiology. — The  patients  who  have  come  under  my  care  have  in- 
variably been  of  a  pronounced  neurotic  type,  usually  of  neurotic  ances- 
try, and  invariably  from  a  neuropathic  environment.  It  is  quite 
usual  to  find  that  a  considerable  quantity  of  milk  has  been  taken  daily. 
Ptosis  of  the  transverse  colon  and  the  elongated  or  ptosed  sigmoid 
(p.  208)  may  be  in  part  responsible  for  some  of  these  cases. 

Symptoms. — The  disease  rarely  follows  an  acute  inflammatory  proc- 
ess in  the  intestine.  In  the  majority  of  instances  there  is  a  history 
of  obstinate  constipation  in  a  markedly  neurotic,  underfed  child.  Con- 
stipation may  have  existed  during  the  patient's  entire  life.  Almost 
without  exception  the  treatment  which  has  been  followed  has  consisted 
in  the  use  of  colon  irrigations  and  various  kinds  of  astringents,  such 
as  solutions  of  tannic  acid,  nitrate  of  silver,  etc.  In  children  with 
mucous  colitis  the  appetite  is  capricious,  the  bowels  are  usually  consti- 
pated, and  the  disposition  is  chronically  irritable.  These  children  are 
apt  to  complain  of  ill-defined  pains  in  the  abdomen,  which  are  never 
very  severe  and  are  not  necessarily  associated  with  the  taking  of  food. 
There  is  usually  slight  generalized  abdominal  pain  on  pressure.  A  child 
four  years  of  age,  under  treatment  at  the  present  time, — the  most  pro- 
nounced case  that  I  have  ever  had  under  my  care, — has  never  had  the 
slightest  evidence  of  pain  of  any  character.  With  the  dejections  there 
is  usually  mucus  in  considerable  amount,  which  is  occasionally  passed 


230  THE    PRACTICE    OF   PEDIATRICS 

in  large  masses,  at  other  times  in  long,  tenacious  strings,  sometimes  re- 
ferred to  as  "ropy."  During  a  period  of  several  consecutive  days  little 
or  no  mucus  may  be  passed ;  then  large  amounts  will  suddenly  appear. 
Treatment. — These  cases  respond  most  quickly  when  local  measures 
which  often  act  as  irritants  to  the  intestinal  mucous  membrane  are 
discarded.  Usually,  as  a  result  of  previous  treatment  and  because 
of  the  nature  of  the  disease,  the  constipation  is  most  obstinate.  To 
prevent  this  I  use  an  injection  of  two  to  three  ounces  of  olive  oil  at 
bed-time,  the  tube  being  introduced  8  inches  into  the  bowel. 
After  breakfast  on  the  following  morning  the  child  is  placed  at  stool, 
and  if  no  passage  occurs  within  fifteen  minutes,  a  glycerin  supposi- 
tory is  inserted.  By  this  means  one  passage  daily  is  insured,  and 
this,  ordinarily,  is  all  that  is  required.  The  use  of  the  suppository 
is  to  be  discontinued  after  a  very  few  days,  as  soon  as  the  habit  of 
evacuation  at  a  certain  time  is  established.  Should  this  method  fail, 
from  one  to  two  drams  of  the  aromatic  fluid  extract  of  cascara  may 
be  given  in  addition,  at  bedtime,  this  medication  being  gradually  di- 
minished and  discontinued  as  soon  as  it  is  demonstrated  that  an  evacua- 
tion will  occur  without  medicine.  A  remedy  of  considerable  value  is 
the  liquid  albolene  (aromatic),  given  in  dosage  of  H  ounce  to  2  ounces 
at  bedtime,  and  continued  in  gradually  diminishing  doses  until  the 
stools  are  free.  Local  measures  other  than  those  suggested  for  consti- 
pation are  not  to  be  employed. 

Diet. — Not  infrequently  these  patients  have  been  taking  a  consider- 
able amount  of  milk.  This  is  immediately  discontinued.  In  its  place 
malted  milk  or  whey  is  given.  The  further  diet  consists  of  whole- 
wheat bread,  animal  broths,  cereals  cooked  three  hours,  eggs,  poultry, 
red  meat,  stewed  fruit,  and  fruit-juices.  Spinach,  stewed  carrots, 
and  asparagus-tips  are  the  only  vegetables  allowed  at  the  beginning 
of  the  treatment,  and  these  by  no  means  should  always  be  given.  Pur^e 
of  peas,  beans,  and  lentils  may  be  given  freely.  The  use  of  butter  is 
also  encouraged.  I  endeavor  to  have  the  patient  take  three  ounces 
daily.     It  may  be  given  on  bread  or  on  the  cereal. 

DriLgs. — Strychnin  and  nux  vomica  appear  to  exert  a  very  bene- 
ficial influence  on  these  cases.  The  combination  of  nux  vomica  and 
quinin  has  been  very  satisfactory.  For  a  child  from  five  to  ten 
years  of  age  the  following  should  be  ordered: 

I^     Tincturaj  nucis  vomicae gtt.  xc 

Quininse  bisulphatis gr.  Ix 

M.  div.  et  ft.  capsulse  No.  xxx. 

Sig. — One  capsule  after  each  meal. 

A  child  suffering  from  mucous  colitis  invariably  shows  a  considerable 
degree  of  malnutrition.  For  details  respecting  sleep,  rest,  exercise, 
and  baths,  all  of  which  are  more  important  than  medication,  the  reader 
is  referred  to  the  section  on  Tardy  Malnutrition  (p.  100). 

HIRSCHSPRUNG'S  DISEASE  (IDIOPATHIC  DILATATION  OF  THE 

COLON) 

Two  forms  of  Hirschsprung 's  disease  are  recognized — the  congenital 
and  the  acquired. 


THE    INTESTINAL    INFANTILISM    OF    HERTER 


231 


The  condition  is  rarely  encountered — probably  not  over  100  cases 
are  to  be  found  in  the  literature.  Only  two  well-marked  cases  have 
come  under  my  observation.  There  is  an  enormous  dilatation  and 
hypertrophy  of  the  colon  without  constriction.  The  greatest  dilatation 
is  found  in  the  transverse  and  descending  colon.  In  the  cases  described 
by  Hirschsprung  there  were  ulcerative  processes  in  the  mucous  mem- 
brane and  submucous  abscesses. 

Etiology. — In  all  cases  the  condition  is 
probably  based  upon  congenital  structural 
defects. 

Symptoms. — The  prominent  symp- 
toms are  obstinate  constipation,  sym- 
metric enlargement  of  the  abdomen  (Fig. 
23),  and  malnutrition. 

The  bowels  may  act  only  once  in  three 
to  six  weeks.  Complete  obstipation  of 
two  or  three  months'  duration  has  been 
reported  (Cautley).  Respiration  is  often 
impeded  because  of  pressure  on  the  dia- 
phragm. For  a  like  reason  the  heart 
action  may  be  interfered  with.  The 
hepatic  and  splenic  dulness  is  obliterated. 

Prognosis. — The  prognosis  for  a  com- 
plete cure  is  unfavorable.  The  patient 
usually  succumbs  to  intercurrent  disease. 

Treatment. — ^Little  is  to  be  expected 
from  treatment,  whether  medical  or  surg- 
ical. Various  operative  procedures  have 
been  attempted.  The  radical  operation 
involving  complete  removal  of  the  colon 
has  been  performed.  As  long  as  it  is 
possible  to  produce  an  evacuation  of  the 
colon  the  patient  may  remain  in  a  fairly 
comfortable  condition.  Laxative  drugs, 
massage,  electricity  and  colonic  irriga- 
tions may  all  prove  useful  as  temporary 
aids. 


Fig.  23.- 


-Hirschsprung's  dis- 
ease. 


THE  INTESTINAL  INFANTILISM  OF  HERTER 

Notwithstanding  the  great  amount  of  scientific  work  accomplished 
by  Christian  A.  Herter,  it  seems  likely  that  his  name  will  be  per- 
petuated in  connection  with- this  condition  of  intestinal  infantilism, 
more  than  by  any  other  work  that  he  did,  for  he  described  a  condition 
that  was  never  before  carefully  studied  and  thus  established  it  as  a 
distinct  disease  with  characteristic  symptoms,  intestinal  flora  and 
changes  in  the  urine  (Freeman).* 

In  this  disease  there  is  an  arrested  physical  development,  the  child 
*  Journal  A.  M.  A.,  vol.  ii,  p.  329-332. 


232  THE    PRACTICE    OF    PEDIATRICS 

is  usualty  well  formed  but  does  not  grow  and  does  not  gain  in  weight. 
A  patient  under  treatment  at  present, — a  female,  is  seven  and  one-half 
years  of  age,  weighs  20  pounds  and  is  34^-^  inches  tall.  No  growth 
has  taken  place  since  she  was  two  years  old, 

A  description  of  this  child  covers  the  symptomatology  in  all.  The 
mental  development  is  normal,  the  patient  can  read  and  write.  In 
addition  to  the  small  stature  there  is  a  marked  enlargement  of  the  abdo- 
men. The  patient  is  of  low  resistance — she  tires  readily  and  is  peevish 
and  unhappy.  She  has  an  enormous  appetite  and  demands  food  about 
five  times  a  day.  The  stools  are  large  and  fatty  in  appearance  and 
contain  a  large  amount  of  fat  and  fatty  acids.  In  Herter's  infantilism 
frequent  attacks  of  diarrhea  are  the  rule.  The  urine  shows  an  excess 
of  putrefactive  products  of  intestinal  origin,  the  indican  and  phenol 
compounds  are  present.  The  bacterial  flora  of  the  intestinal  tract, 
according  to  Herter,*  are  gram-positive  organisms  of  the  bacillus 
bifidus  type,  bacillus  infantilis  type  and  cocco-bacillary  forms.  There 
is  a  marked  absence  of  gram-negative  bacilli  in  the  stools. 

Infants  of  this  type  are  very  discouraging  patients.  No  pro- 
nounced improvement  is  to  be  expected  from  any  line  of  treatment. 
Milk,  rare  meat  and  poultry,  and  cereals,  such  as  oatmeal,  and  the 
wheat  derivatives  constitute  the  basis  of  the  diet. 

Freeman  feels  that  he  has  observed  benefit  from  the  use  of  extract 
of  pancreas  3  grains,  three  times  daily  in  the  form  of  an  enteric  pill. 

INCONTINENCE  OF  FECES 

Incontinence  of  feces  is  a  normal  condition  during  infancy,  con- 
trol being  established  without  training  during  the  second  year  or  earlier. 
In  well-trained  infants  I  have  seen  the  bowel  function  under  perfect 
control  at  the  third  month.  This  is,  however,  unusual.  With  a 
very  little  teaching  it  may  be  accomplished  at  the  sixth  month.  In- 
continence of  feces  in  older  children  occurs  during  acute  inflammatory 
conditions,  particularly  when  the  colon  is  the  seat  of  the  lesion.  In- 
continence may  also  occur  in  asthenic  states,  as  in  grave  pneumonia, 
in  typhoid  fever,  and  in  severer  types  of  the  exanthemata;  and  it  may 
occur  accidentally  as  the  result  of  fright,  shock,  or  severe  straining. 
It  may  result  from  spinal  cord  disease  or  injury,  and  is  sometimes 
present  in  spina  bifida,  in  which  event  the  fecal  incontinence  may  be 
compared  to  incontinence  of  the  urine.  I  have  seen  5  such  cases. 
In  2  the  condition  had  existed  for  months.  The  desire  for  an 
evacuation  was  urgent  and  without  warning,  and  was  uncontrollable. 

Incontinence  of  feces,  as  a  condition  independent  of  early  infancy 
and  illness,  is  of  exceedingly  unusual  occurrence.  I  have  seen  but  5 
cases — 2  in  boys,  one  four  and  the  other  seven  years  of  age.  In  these  2 
the  condition  had  persisted  for  months.  The  desire  for  an  evacuation 
came  with  great  urgency  and  was  uncontrollable.  In  2  other  cases 
there  was  occasional  incontinence  due  to  a  relaxed  sphincter,  probably 
*  Herter's  "Infantilism,"  Macmillan  Co.,  1908. 


INTUSSUSCEPTION  233 

produced  by  frequent  irrigations.  These  responded  to  the  treatment 
outlined  below.  In  the  fifth  case  there  was  no  response  to  any  treat- 
ment instituted.  The  patient  was  a  boy  six  and  three-quarter  years 
of  age,  and  had  suffered  from  the  incontinence  for  a  year  and  two 
months.  He  was  under  treatment  for  two  weeks;  no  improvement 
resulted,  and  he  passed  from  observation. 

Treatment.^ — ^The  treatment  consisted  in  the  removal  of  green  vege- 
tables and  fruit  from  the  diet,  allowing  only  a  small  amount  of  starches, 
such  as  bread,  potato,  and  cereals.  Eggs,  meat,  skimmed  milk,  junket, 
custard,  etc.,  were  given  freely.  The  medicine  comprised  15  drops  of 
the  tincture  of  the  muriate  of  iron  in  glycerin  and  water,  given  every 
four  hours,  with  1  grain  of  Dover's  powder  and  20  grains  of  subnitrate 
of  bismuth  (Squibb)  given  three  times  daily.  Cases  which  do  not  re- 
spond promptly  to  diet  and  medication  should  have  the  advantage  of 
surgical  procedures. 

INTUSSUSCEPTION 

Intussusception  of  the  bowel  consists  of  a  prolapse — an  invagination 
— of  a  portion  of  the  intestine  into  an  immediately  adjoining  portion. 

Types. — While  certain  portions  of  the  intestine  are  particularly 
liable  to  be  involved,  the  invagination  may  take  place  in  any  portion 
of  the  gut.  Thus  the  small  intestine  may  be  the  part  involved — the 
enteric  form.  The  colon  alone  may  be  involved — the  colic  type.  By 
far  the  most  common  form  is  the  prolapse  of  the  cecum,  and  more  or 
less  of  the  ileum  into  the  colon,  the  valve  forming  the  apex  of  the  tumor. 
This  is  known  as  the  ileocecal  type. 

Invagination  Found  at  Autopsy. — At  autopsy  it  is  of  most  common 
occurrence  to  find  invagination  of  the  small  intestine.  I  have  repeat- 
edly seen  6  to  8  invaginations  in  one  subject.  They  occur  at  death,  and 
are  of  no  significance.  It  is  unusual  to  find  more  than  4  or  5  inches  of 
the  gut  involved. 

Etiology. — The  cause  of  the  intussusception  is  unknown  in  the 
great  majority  of  cases.  Various  theories  have  been  advanced  from 
time  to  time,  none  of  which  deserves  mentioning.  Occasionally  local 
causes  will  explain  the  condition.  In  one  of  my  cases  Meckel's  diver- 
ticulum caused  the  intussusception.  In  another  there  was  a  persistent 
incomplete  reducible  invagination  of  the  transverse  and  descending 
colon  into  the  sigmoid.  It  was  impossible  to  keep  the  parts  in  the  nor- 
mal position,  and  laparotomy  was  resorted  to  in  order  to  learn  the  cause 
of  the  prolapse.  The  entire  colon  was  found  displaced,  the  hepatic 
flexure  being  bound  to  the  abdominal  wall  by  a  firm  adhesion  one-half 
inch  above  the  umbilicus.  This  caused  a  displacement  downward  of 
the  transverse  and  descending  colon,  which  underwent  invagination. 
A  case  in  my  service  at  the  Babies'  Hospital  showed  that  the  invagina- 
tion had  taken  place  at  the  site  of  a  large  and  thickened  Beyer's  patch 
in  the  lower  ileum.  Here,  evidently,  the  gut  was  more  resistant,  and 
the  portion  above,  during  active  peristalsis,  slipped  into  the  less  motile 
section. 


234  THE    PRACTICE    OF    PEDIATRICS 

It  is  peculiar  that  nearly  all  the  cases  occur  in  well-nourished, 
vigorous,  breast-fed  babies. 

Age. — The  age  incidence  is  striking.  The  majority  of  the  cases 
occur  between  the  third  and  ninth  months  of  life.  My  youngest  pa- 
tient was  ten  days  old.  Holt's  statistics  of  358  collected  cases  are  as 
follows : 


28  cases  under  4  months 
113       "    from    4  to  6  months 
71      "■      "       7  to  9       " 


18  cases  from  10  to  12  months 
32     "  "       1  to    2  years 

96     "         "       2  to  10  " 


Symptoms. — The  onset  is  usually  sudden,  with  evidence  of  pain  and 
vomiting.  A  further  early  and  very  important  sign  is  the  marked 
prostration,  which  is  much  more  pronounced  than  in  an  ordinary  gas- 
tro-enteric  disease.  The  child  in  a  few  hours  may  look  very  ill.  There 
is  cyanosis,  and  the  pulse  is  rapid  and  small.  I  have  observed  this 
symptom-complex  in  several  cases.  The  vomiting,  which  is  very 
active,  is  repeated  at  fairly  short  intervals,  and  after  the  stomach  is 
emptied  bile-stained  mucus  is  ejected  with  much  straining.  Medica- 
tion, food,  and  water  are  ejected  as  soon  as  they  reach  the  stomach. 
There  is  evident  tenesmus;  the  child  strains,  and  at  first  passes  normal 
bowel  contents,  followed  by  bile-stained  mucus,  and  later  clear  mucus 
streaked  with  blood — a  most  reliable  diagnostic  sign.  Blood  is  not 
always  present.  In  some  instances  only  white,  tenacious  mucus  is 
passed  or  removed  on  the  examining  finger.  On  the  other  hand  it 
may  be  present  in  large  amount,  constituting  a  very  definite  hemor- 
rhage. The  prostration,  urgent  at  the  beginning,  increases,  and  the 
patient  may  die  of  shock  before  operation  is  attempted. 

The  Presence  of  Tumor.- — -If  the  case  is  seen  early,  a  sausage-shaped 
tumor  may  be  felt,  or  the  rounded  apex  of  the  tumor  may  be  felt  by  rec- 
tal examination  if  the  descending  colon  is  involved.  If  the  patient  is 
not  seen  until  several  hours  or  days  have  elapsed,  the  accumulation  of 
gas  in  the  intestines  renders  the  palpation  of  a  tumor  impossible. 

Occasionally  a  case  is  seen  in  which  the  onset  is  more  gradual,  in 
which  gas  and  bile-stained  mucus  will  be  passed  for  a  day  or  two.  This 
indicates  that  the  invagination  is  not  sufficient  to  close  the  lumen  of  the 
gut.  Finally,  only  blood  and  mucus  are  passed  and  the  obstruction  is 
complete.  Three  or  four  days  may  be  required  to  bring  this  about. 
Vomiting  is  a  less  pronounced  symptom  in  these  cases  of  gradual 
development. 

vStercoraceous  vomiting  does  not  occur  in  young  infants. 

The  Temperature. — The  temperature  range  is ,  of  no  significance. 
In  many  cases  the  temperature  is  never  above  100°F. 

Diagnosis. — There  is  no  satisfactory  excuse  for  so  many  failures  in 
diagnosing  intussusception  in  infants.  The  reason  for  the  failure  to 
appreciate  the  condition  is  because  physicians  too  readily  interpret 
active  vomiting,  with  green  mucous  and  bloody  stools,  as  significant  of 
gastro-enteric  intoxication. 

Distinguishing  features  of  intussusception  are:  Vomiting,  sudden 
and  urgent,  in  well  infants,  who  may  be  breast-fed;  shock  and  collapse 


INTUSSUSCEPTION  235 

out  of  proportion  in  severity  to  the  other  symptoms;  the  passage  of 
clear,  mucous  stools  streaked  with  blood,  together  with  the  presence  of 
pain  of  a  paroxysmal  nature,  the  absence  of  the  passage  of  flatus,  and 
the  sudden  distention  of  the  abdomen. 

The  presence  of  a  tumor  which  can  be  felt  either  by  abdominal  pal- 
pation or  in  the  rectum  occurs  in  perhaps  80  per  cent,  of  the  cases.  In 
cases  of  ileocecal  intussusception  the  tumor  may  be  difficult  to  map 
out,  particularly  if  there  is  much  distention  of  the  abdomen.  Under 
these  circumstances  anesthesia  should  be  used  in  suspicious  cases. 
Rectal  examination  is  always  a  valuable  aid  and  should  never  be 
neglected. 

Prognosis. — The  prognosis  in  the  immediate,  complete  case  depends 
largely  upon  the  time  of  making  the  diagnosis  and  the  promptness  of 
operative  procedures.  The  chance  for  recovery  from  operation  de- 
creases rapidly  with  each  succeeding  day. 

It  is  impossible  to  give  statistics  of  value.  It  is  safe  to  say  that 
over  50  per  cent,  of  these  cases  are  curable  by  some  means  if  they  are 
diagnosed  early.  The  high  mortality — 50  to  80  per  cent. — is  due  to 
two  conditions :  the  tender  age  of  the  patients  and  the  fact  that  the 
cases  seen  in  consultation  and  those  seen  in  children's  hospitals  usually 
have  been  treated  for  something  other  than  intussusception.  Some- 
times such  treatment  has  been  continued  for  several  days.  By  the  time 
those  cases  reach  the  hands  of  the  surgeon  there  may  be  extensive  ad- 
hesions, gangrene  of  the  involved  portion  of  the  intestine,  and  an 
exhausted  child  to  deal  with. 

Treatment. — Reduction  by  Water-pressure. — It  is  my  custom,  in  any 
case,  first  to  send  for  the  surgeon  and  then  make  one  attempt  at  reduc- 
tion by  water-pressure:  A  well-oiled  catheter.  No.  18  American,  or  a 
small  rectal  tube,  is  attached  to  the  small  hard-rubber  tip  of  a  fountain- 
syringe.  Two  quarts  of  a  normal  salt  solution  are  placed  in  the  bag, 
which  is  hung  at  an  elevation  of  four  feet  above  the  child's  body.  The 
colon,  or  that  part  of  it  below  the  intussusception,  is  slowly  filled  with 
the  warm  salt  solution.  A  small  wet  towel  is  tightly  wrapped  around 
the  catheter,  and  fairly  strong  pressure  is  made  at  the  anus  by  an 
assistant,  in  order  to  prevent  the  escape  of  the  fluid.  With  the  child  on 
his  back  with  both  hands  free,  the  buttocks  are  elevated  on  a  pillow  or 
bed-pan  at  a  plane  10  inches  above  the  shoulders.  In  the  cases  in  which 
the  tumoris  palpable,  an  attempt  is  made,  by  gentle  abdominal  manipu- 
lation, to  reduce  the  intussusception.  This  in  two  cases  I  have  thus 
succeeded  in  doing.  Prolonged  and  repeated  attempts  at  reduction 
should  not  be  practised.  An  early  operation  gives  the  child  a  far 
better  chance  of  life  than  does  any  temporizing  measure. 

Illustrative  Cases. — Case  1. — A  child,  two  and  one-half  years  of  age,  was  brought 
to  my  office  at  midnight  with  a  history  of  a  severe  attack  of  colic  about  9  o'clock, 
which  was  followed  by  severe  attacks  of  vomiting  and  two  stools  of  mucus  and 
blood.  Gentle  manipulation  of  the  abdomen  showed  a  large,  sausage-shaped 
tumor,  about  five  inches  long,  in  the  left  hypochondrium,  which  I  diagnosed  as  an 
intussusception.  The  tumor  could  not  be  felt  by  rectal  examination.  Water- 
pressure,  as  described  above,  with  abdominal  manipulation,  reduced  the  intus- 
susception in  a  few  minutes. 


236  THE    PRACTICE    OF    PEDIATRICS 

Case  2. — The  other  patient  was  a  baby  nine  months  of  age.  I  saw  the  child  in 
consultation  after  the  intussusception  had  existed  for  six  days.  The  child  was 
unconscious  and  in  profound  collapse.  He  was  pulseless,  but  the  heart-sounds 
could  be  faintly  distinguished  by  the  aid  of  stethoscope.  The  rectal  temperature 
was  96°F.  The  abdomen  was  greatly  distended.  The  child  had  been  treated  for 
cholera  infantum,  although  for  five  days  nothing  but  white  mucus  tinged  with 
blood  had  been  passed.  Palpation  revealed  a  sausage-shaped  tumor  extending 
along  the  entire  left  side  of  the  abdomen,  which,  in  spite  of  the  abdominal  disten- 
tion, could  easily  be  made  out  by  firm  pressure.  The  child  was  unconscious,  so 
that  there  was  no  resistance  to  the  examination.  By  rectal  examination  the  pro- 
jection of  the  involuted  gut,  which  resembled  the  cervix  uteri,  could  readily  be 
distinguished.  The  condition  of  the  child  precluded  all  chance  of  surgical  relief, 
and  I  hesitated  to  use  water-pressure,  fearing  that  the  gut  might  be  gangrenous 
and  a  rupture  result,  or  that  there  might  be  adhesions  sufficient  to  prevent  reduc- 
tion, and  that  the  child  might  die  during  the  manipulations.  I  explained  the 
situation  to  the  parents,  who,  after  considerable  urging,  consented  to  a  trial  being 
made.  The  patient  was  accordingly  given  Hoo  grain  of  strychnin,  1  drop  of  tinc- 
ture of  strophanthus,  and  30  drops  of  brandy  hypodermically.  The  water- 
pressure  was  applied  in  the  usual  way,  and  it  was  with  the  greatest  surprise  and 
with  supreme  satisfaction  that  I  felt  the  tumor  slowly  give  way,  to  be  followed  by 
an  expulsion  of  gas  and  a  quantity  of  very  fetid  fecal  matter.  A  hot  colon  flushing 
at  110°F.  with  a  normal  salt  solution  was  given  a  few  minutes  later.  This  was  all 
retained,  and  six  hours  later  12  ounces  more  were  given.  Hot-water  bottles  and 
bags  were  placed  about  the  child.  He  had  sufficiently  revived  in  an  hour  after 
the  first  colon  flushing  to  be  able  to  swallow  diluted  brandy  and  egg-water,  both 
of  which  were  freely  given.     A  rapid  recovery  followed. 

This  case,  to  me,  was  interesting  in  many  ways,  particularly  as  it  emphasized 
what  we  sometimes  see  in  work  among  children  when  victory  is  snatched  from  the 
jaws  of  evident  defeat — that  we  should  never  cease  our  efforts  so  long  as  life  lasts. 

It  is  my  practice  to  make  but  one  attempt  at  reduction  by  water- 
pressure.  When  this  does  not  succeed  after  a  five-minute  trial,  imme- 
diate operation  gives  the  patient  his  only  chance  of  recovery. 

CONSTIPATION 

Constipation  in  the  young  has  in  many  instances  been  ascribed  to 
the  influence  of  heredity.  It  is  undoubtedly  true  that  a  predisposition 
to  deficient  musculature  in  the  bowel  not  infrequently  exists  apart  from 
other  assignable  cause.  In  most  cases,  however,  muscular  impairment 
and  atony  of  the  intestine  are  induced  by  prolonged  improper  feeding, 
constitutional  diseases  (such  as  rickets)  resulting  in  deficient  general 
nutrition,  or  artificial  assumption  of  the  normal  work  of  the  intestine 
by  the  too  frequent  administration  of  enemata  or  suppositories. 

Deficient  fat  content  in  the  milk  of  young  infants,  and  insufficient 
solid  food  in  the  diet  of  children  over  one  year  of  age,  probably  are 
responsible  for  a  majority  of  the  cases.  The  digestive  organs  demand 
not  only  elements  for  assimilation,  but  a  certain  amount  of  food  residue 
to  act  as  a  stimulus  to  perfectly  normal  musculature.  The  results  of 
the  absence  of  a  fair  amount  of  this  food  residue  in  the  diet  are  most 
apparent  in  children  between  the  first  and  third  years,  who  receive 
over  a  quart  of  milk  daily,  administered  in  frequent  instalments,  and 
from  force  of  parental  habit  or  perverted  desire  on  their  own  part  are 
deprived  of  such  important  dietetic  ingredients  as  cereals,  vegetables, 
and  fruit.  Such  children  are  almost  invariably  sufferers  from  chronic 
constipation. 


CONSTIPATION  237 

The  cases  commonly  ascribed  to  deficient  secretion  on  the  part  of 
the  intestinal  glands  and  liver  are  also  frequently  of  dietetic  origin. 

Mechanical  defects  and  abnormalities  may  be  entirely  responsible 
for  the  most  obstinate  constipation.  Localized  proctitis,  fissures  and 
hemorrhoids,  and  sphincter-spasm  may  be  important  causative  factors. 
Congenital  narrowing  of  the  gut,  elongated  sigmoid  (Fig.  19),  prolapse 
of  the  colon  (Fig.  20),  hernia,  and  congenital  dilatation  of  the 
colon  (Hirschspring's  disease)  deserve  to  be  borne  in  mind  in  this 
connection. 

Before  instituting  treatment  of  any  nature  it  is  necessary  to  know 
that  no  mechanical  cause  exists. 

Bowel  Evacuation  Necessary. — In  order  to  keep  the  infant  or 
young  child  in  good  physical  condition,  one  free  evacuation  of  the 
bowels  is  required  once  in  twenty-four  hours.  While  two  or  three 
evacuations  daily  in  a  nursing  or  bottle  baby  may  be  desirable,  this 
number  is  not  absolutely  necessary.  When  there  are  more  than  four 
passages  in  twenty-four  hours,  it  means  that  something  is  wrong  with 
the  intestinal  tract.  This,  however,  may  not  be  of  such  a  nature  as  to 
require  radical  means  for  its  correction.  Thus,  in  many  nursing  babies 
who  are  supplied  with  a  high-fat  breast-milk,  there  may  be  several  thin 
greenish  stools  in  twenty-four  hours,  in  spite  of  which  condition  the 
child  thrives  satisfactorily.  It  is  well  in  these  cases  to  attempt  to  re- 
duce the  fat  in  the  breast-milk  by  measures  suggested  elsewhere,  but  by 
no  means  should  the  nursing  be  interdicted  if  the  baby  is  making  a 
reasonable  gain  in  weight.  The  proof  of  successful  nursing  is  a  thriv- 
ing child,  not  the  character  of  the  stool.  The  habit  of  an  evacuation  at 
a  certain  time  each  day  is  one  of  the  most  important  preventives  of 
constipation  in  an  infant.  There  is  a  standing  order  in  every  household 
where  I  have  such  a  patient,  to  the  effect  that  the  child  is  never  put  to 
bed  for  the  night  unless  the  bowels  have  moved  during  the  preceding 
twenty-four  hours.  Either  a  simple  soap-and- water  enema  or  a  small 
glycerin  suppository  is  employed.  The  enema  is  preferred,  from  4  to  8 
ounces  of  the  soap-water  being  used.  The  suppository  is  used  only 
when,  for  any  good  reason,  the  enema  is  not  available.  Placing  the 
child  at  stool  immediately  after  the  morning  bottle  is  one  of  the  means 
of  establishing  the  habit  of  an  evacuation  at  a  definite  time  each  day. 
The  child  soon  appreciates  the  reason  for  this  position  and  acts  accord- 
ingly. This  practice  may  be  begun  when  the  child  is  five  or  six  months 
of  age. 

Defective  Bowel  Evacuation. — Defective  bowel  evacuation  in  in- 
fants and  young  children  is  a  form  of  constipation  very  apt  to  be  over- 
looked, and  for  this  reason  it  is  put  under  an  independent  heading.  As 
long  as  an  evacuation  takes  place  daily  it  is  supposed  to  be  sufficient. 
Even  though  a  passage  takes  place  daily  and  voluntarily,  if  it  is  dry 
and  comes  away  in  pieces  or  in  hard  balls,  or  is  firmly  formed  without 
the  moist  surfaces  caused  by  the  presence  of  mucus  and  water,  it  is 
practically  certain  that  the  evacuation  is  not  complete  and  that  fecal 
matter  is  retained  in  the  intestine.     This  type  of  constipation  is  often 


238  THE    PRACTICE    OF    PEDIATRICS 

associated  with  ptosis  of  the  stomach  (p.  177).  The  ptosed  stomach 
always  empties  very  slowly  and  the  absorption  of  the  water  from  the 
intestinal  contents  is  then  more  complete.  This  may  occur  at  any  age, 
and  when  the  condition  persists,  there  results,  oftentimes,  an  intestinal 
toxemia,  with  the  manifestations  referred  to  under  that  caption. 
The  same  methods  of  treatment  are  to  be  followed  as  suggested  for 
constipation  at  the  various  ages  of  infancy  and  childhood.  Usually, 
however,  in  this  type  of  constipation,  dietetic  measures  are  sufficient. 

Constipation  in  Nurslings. — There  are  many  nursing  infants  who 
are  thriving  and  well  in  every  respect,  except  that  they  are  constipated. 
Bowel  evacuation  is  greatly  delayed  or  does  not  occur  without  aid. 
Our  first  step  in  the  management  of  these  cases  is  to  examine  into  the 
daily  life  and  habits  of  the  mother.  A  factor  in  the  etiology  of  con- 
stipation in  the  infant  is  constipation  in  the  mother.  Treatment  of 
the  mother  will  often  relieve  the  child.  If,  however,  the  constipation 
in  the  mother  is  not  relieved,  the  subsequent  treatment  directed  toward 
the  child  will  be  much  less  effective.  Nursing  women  who  drink  a 
great  deal  of  tea  are  apt  to  be  constipated,  and  their  infants  are  similarly 
affected.  The  nurslings  of  mothers  who  lead  indolent  lives,  taking  but 
little  exercise,  are  likewise  sufferers  from  constipation. 

Treatment  of  the  Mother. — Errors  in  the  mother's  diet  and  habits 
of  life  must  be  corrected  and  the  scheme  carried  out  which  is  recom- 
mended under  Maternal  Nursing. 

When  a  proper  regime  for  the  mother  has  been  established,  the 
breast-milk  should  be  examined.  While  high  proteid  may  contribute 
to  constipation,  this  factor,  in  my  observation,  is  rarely  a  cause. 
Low  fat,  from  1.5  to  2.5  per  cent.,  with  normal  proteid  is  much  oftener 
found  to  be  present. 

Often  in  such  cases  the  fat  in  the  mother's  milk  may  be  increased 
by  the  use  of  some  form  of  alcohol,  given  with  the  meals.  Wine,  beer, 
ale,  porter,  or  the  liquid  malt  preparations  may  be  given,  the  mother 
being  allowed  to  make  her  own  selection  according  to  her  taste.  The 
free  eating  of  red  meats  also  increases  the  fat  in  the  milk. 

Several  years  ago  a  series  of  observations  were  made  in  the  New 
York  Infant  Asylum  relating  to  the  effects  of  diet  on  breast-milk. 
It  was  found  that  in  some  cases  the  fat  could  be  increased  from  1  to 
2  per  cent,  by  the  addition  of  alcohol  to  the  mother's  diet.  The  value 
of  the  various  galactagogues  on  the  market  depends,  in  all  probability, 
upon  the  alcohol  which  they  contain. 

Treatment  of  the  Child. — A  very  tight  sphincter  is  the  cause  of  con- 
stipation in  a  small  proportion  of  nurslings;  and  before  beginning 
other  treatment  in  such  cases  the  sphincter  should  be  stretched  by 
passing  a  protected  index-finger  into  the  rectum.  As  an  aid  to  nutrition 
and  as  a  laxative,  a  valuable  addition  to  the  diet  of  the  constipated 
breast-fed  infant,  when  the  mother's  milk  is  found  weak  in  fat,  is  cow's- 
milk  cream,  3^  to  1  teaspoonful  of  which  may  be  given  before  every 
second  nursing  or  before  every  nursing,  according  to  the  age  of  the 
child  and  the  capacity  for  fat  digestion.     Children  during  the  early 


CONSTIPATION  239 

months  of  life  take  pure  cod-liver  oil  readily,  and  oil,  like  cream,  may- 
serve  the  double  function  of  a  food  and  a  laxative.  Establishing  by- 
careful  instruction  the  habit  of  an  evacuation  of  the  bowels  at  a  certain 
time  every  day,  is  a  valuable  measure. 

Drugs. — Drug-giving  is  rarely  necessary  in  treating  young  children 
and  should  be  resorted  to  only  -when  other  measures  fail.  In  case 
drugs  are  necessary,  those  most  useful  ordinarily  are  the  preparations  of 
cascara  sagrada.  The  aromatic  fluidextract  (Parke,  Davis  &  Co.) 
is  palatable  and  may  be  given  in  sufficient  doses  to  be  effective  once 
or  twice  daily.  The  milk  of  magnesia  with  equal  parts  of  the  aromatic 
syrup  of  rhubarb,  given  in  doses  of  from  1  to  3  teaspoonfuls  daily,  is 
an  agreeable  and  usually  an  effective  combination.  The  liquid  albo- 
lene  (aromatic) ,  in  1  to  4  dram  doses,  acting  as  a  lubricant,  often  gives 
surprisingly  good  results. 

Enemata  and  Suppositories. — The  use  of  water  enemata  and  sup- 
positories is  not  to  be  advised  as  a  routine  measure.  The  habit  of 
depending  upon  them  is  readily  established,  the  bowel,  by  their  fre- 
quent use,  becomes  insensitive  to  stimulation,  and  in  a  few  weeks  they 
fail  to  act.  I  have  had  many  mothers  come  to  me  in  great  distress 
when  this  stage  was  reached.  When  the  stool  is  dry  and  hard  and 
is  passed  with  difficulty,  the  injection  of  two  ounces  of  warm  sweet 
oil  at  bedtime  is  of  advantage.  This  is  not  intended  to  produce 
an  immediate  evacuation,  but  rather  to  act  as  a  lubricant  for  the 
evacuation  expected  the  following  morning. 

Malted  Foods. — It  is  elsewhere  advised  that  the  nursing  baby  be 
given  one  bottle-feeding  daily.  The  malted  proprietary  foods  are 
distinctly  laxative  to  many  children.  It  has  long  been  my  custom, 
when,  in  a  nursing  infant,  a  condition  of  constipation  exists  which  is 
not  relieved  by  careful  regulation  of  the  mother's  diet,  to  prescribe 
one  feeding  of  malted  milk  daily,  in  the  strength  of  one  teaspoonful 
to  an  ounce  of  water.  Some  children  will  not  take  malted  milk  of  this 
strength,  as  the  sweet  taste  is  objectionable.  In  such  cases  it  may 
be  given  weaker  at  the  beginning,  or  it  may  be  given  in  a  milk  mix- 
ture suitable  to  the  age  of  the  child.  When  it  is  used  in  this  way, 
there  should  be  no  addition  of  sugar.  Malted  milk  or  Mellin's  food 
may  be  used  in  a  quantity  equal  of  that  of  the  sugar. 

Massage  is  a  most  valuable  means  of  treatment  in  the  constipation 
of  older  children,  but  in  nurslings  and  in  the  bottle-fed  of  tender  age, 
on  account  of  the  restlessness  and  crying,  is  not  always  practic- 
able, and  to  be  effective  it  should  be  given  only  by  those  skilled  in 
its  use;  therefore,  unless  the  case  is  an  extreme  one,  and  all  other 
measures  have  failed,  massage  is  not  to  be  employed  in  the  very 
young. 

Constipation  in  the  Bottle-fed. — Before  undertaking  the  treatment 
of  constipation  in  any  infant  the  rectum  should  be  examined  to 
determine  the  presence  or  absence  of  sphincter  spasm  (p.  238).  In  the 
bottle-fed,  inactivity  of  the  bowel  is  more  easily  managed  than  in  the 
nurslings,  because,  in  dealing  with  the  former,  we  are  in  a  better  position 


240  THE    PRACTICE    OF    PEDIATRICS 

to  adapt  the  food  to  the  child 's  digestive  pecuharities.  As  a  rule, 
constipated  bottle  babies  should  have  a  reasonably  high  fat — 3.5  to  4 
per  cent. — and  sugar  up  to  at  least  7  per  cent.  This  rule,  however, 
is  open  to  exceptions ;  a  few  of  the  most  obstinate  cases  of  constipation 
that  have  come  under  my  care  have  been  fed  on  a  very  high  fat, 
the  constipation  being  due  to  fat  indigestion.  It  is  extremely  rare  to 
find  a  child  who  can  digest,  day  after  day,  a  milk  mixture  containing 
more  than  4  per  cent,  of  cow's-milk  fat. 

The  Proteid. — Cow's-milk  casein,  although  probably  the  most  fruit- 
ful factor  in  causing  constipation  in  bottle-fed  babies,  nevertheless,  is 
necessary  for  the  child's  nutrition.  A  considerable  reduction,  such 
as  may  be  obtained  by  giving  a  mixture  of  cream,  sugar,  and  water, 
may  relieve  the  constipation,  but  the  child  thus  fed  will  suffer  from 
a  nutritional  standpoint,  and  instead  of  being  constipated  will  be- 
come rachitic,  which  is  much  worse.  In  not  a  few  instances  I  have 
seen  malnutrition  result  from  cutting  down  the  proteid  in  the  effort 
to  relieve  constipation. 

The  child's  growth  and  development  must  never  be  held  subservi- 
ent to  anything  else.  A  child  under  six  months  of  age  will  not  thrive 
satisfactorily  on  less  than  1  per  cent,  of  proteid  as  found  in  cow's  milk. 
He  is  entitled  to  at  least  1.5  per  cent.,  and  thrives  best  when  this 
amount  is  given.  The  relief  of  the  constipation  can  in  almost  every 
instance  be  accomplished  by  other  means  than  a  too  great  reduction  in 
the  casein — the  most  nutritive  element  in  the  infant 's  food. 

Milk  given  constipated  infants  should  always  be  raw,  as  cooking 
increases  its  constipating  tendency. 

Laxative  Agents  in  the  Food. — The  simplest  means  of  treating 
constipation  in  the  bottle-fed  is  by  the  employment  of  a  laxative  agent 
in  the  food,  and  when  such  an  agent  adds  to  its  nutritive  value,  it 
serves  a  double  purpose.  Instead  of  water  as  a  diluent,  oatmeal- 
water  No.  1  (see  Formulary)  may  be  employed.  The  malted  proprie- 
tary foods,  such  as  Mellin's  food  and  malted  milk,  are  laxative  to  most 
children.  Mellin  's  food  is  composed  largely  of  dextrose  and  maltose, 
which  are  laxative  sugars,  and  therefore  may  be  used  in  place  of  sugar- 
of-milk  or  cane-sugar  in  the  food  mixture,  for  the  purpose  of  relieving 
constipation.  In  some  instances  I  substitute  a  feeding  of  malted  milk 
with  from  4  to  8  ounces  of  water  once  daily  for  the  regular  milk  food, 
the  quantity  and  strength  depending,  of  course,  upon  the  age  of  the 
child. 

Drugs  and  Local  Measures. — Dietetic  measures  should  always  be 
tried  before  drugs  are  resorted  to.  One  or  two  teaspoonfuls  of  milk  of 
magnesia  in  one  bottle  daily  may  be  recommended  as  a  temporary 
expedient  in  some  cases.  The  magnesia  may  be  of  service  until  the 
condition  is  controlled  by  the  diet.  The  aromatic  fluidextract  of 
cascara  sagrada,  in  doses  of  from  15  drops  to  one  dram,  may  be  tried 
if  success  does  not  follow  the  use  of  the  magnesia. 

Water  enemata  and  suppositories  should  be  used  only  as  tem- 
porary  measures.     Orange-juice,   2  teaspoonfuls  twice  daily  before 


CONSTIPATION  241 

feedings,  is  worthy  of  trial,  and  is  of  antiscorbutic  value  for  children 
artifically  fed.  Sweet  oil  and  the  pure  cod-liver  oil  may  be  also  used 
in  doses  from  30  drops  to  2  drams,  three  times  daily,  after  feedings. 
Oils  produce  beneficial  effects  not  only  as  laxatives,  but  also  as  aids  to 
nutrition.  Acting  purely  as  a  lubricant,  liquid  albolene  (aromatic) 
in  dosage  of  2  drams  to  3^^  ounce,  once  daily  after  the  evening  meal,  is 
of  much  service  in  many  cases. 

Oil  Injections. — In  case  the  stool  remains  hard  and  dry  in  spite 
of  the  above  suggestions,  an  injection  of  2  ounces  of  warm  sweet  oil 
may  be  given  at  bedtime  every  night,  not  with  a  view  to  inducing  a 
passage  at  the  time,  but  as  a  lubricant  to  the  parts  and  as  a  solvent 
of  the  hard  fecal  masses. 

Constipation  in  Older  Children. — Etiology. — Probably  the  most 
potent  dietetic  factor  in  causing  constipation  in  children  of  the  "run- 
about" age  is  the  use  of  full  milk,  crackers,  and  dry  bread-stuffs. 
Particularly  is  this  apt  to  be  the  case  if  the  milk  is  boiled.  Con- 
stipation may  also  be  occasioned  by  too  great  concentration  of 
the  food,  insufficient  volume  being  furnished  to  produce  copious 
evacuations. 

Local  Causes. — In  a  great  majority  of  children  the  freer  feed- 
ing following  weaning  from  the  breast  and  bottle  relieves  the  ten- 
dency to  constipation  from  which  many  suffer  during  the  earlier 
months  of  life.  In  a  small  percentage  of  cases,  however,  such  relief 
is  not  furnished,  and  the  child  will  require  the  attention  of  a  phy- 
sician. In  making  the  physical  examination  of  a  case  of  this  nature, 
special  care  should  be  directed  toward  the  examination  of  the  rectum, 
in  order  that  local  causes,  such  as  fissures,  hemorrhoids  or  sphincter 
spasm  may  be  eliminated.  If  fissures  are  present,  the  child  will  use 
every  effort  to  prevent  a  bowel  movement. 

Mechanical  Obstruction. — Elongation  of  the  sigmoid  (p.  208), 
ptosis  of  the  colon  and  cecum  (p.  208),  plaj''  a  part  hitherto  unsus- 
pected as  the  causation  of  constipation.  Recently  much  light  has 
been  thrown  on  many  difficult  and  obstinate  cases  by  the  use  of  the 
Roentgen  ray.  Mechanics  play  an  immediate  role  in  constipation  as 
will  be  appreciated  by  referring  to  Fig.  19.  The  long  sigmoid  loop 
is  an  important  feature  in  constipation. 

Regular  Habits. — As  a  rule,  children  who  are  presented  for  treat- 
ment after  the  second  year  have  not  had  the  benefit  of  carefully  regu- 
lated habits  of  life,  so  that  our  first  step  is  to  correct  bad  habits  that 
may  have  a  bearing  on  the  condition,  and  to  teach  good  habits.  The 
desirability  of  establishing  in  the  child  the  habit  of  a  bowel  evacuation 
at  a  certain  definite  time  every  day  should  be  impressed  upon  the 
mother  or  nurse.  In  order  to  bring  this  about,  an  attempt  should  be 
made  to  induce  a  movement  of  the  bowels  by  voluntary  effort  every 
morning  after  breakfast.  Not  a  few  children  are  too  busy,  too  active 
in  their  play,  to  respond  to  the  call  of  nature  when  it  comes,  and  if 
it  can  be  repressed,  they  say  nothing  about  it.  If  a  certain  time  of 
the  day  is  selected  for  the  evacuation,  and  if  the  child  is  required  to 
16 


242  THE    PRACTICE    OF    PEDIATRICS 

remain  at  stool  until  it  occurs  naturally,  or  by  means  of  a  suppository 
after  fifteen  minutes  have  elapsed,  much  is  accomplished  by  this  means 
alone  toward  establishing  the  habit. 

Diet. — Ultimately,  much  may  be  accomplished  in  these  cases  by 
diet.  Foods  other  than  milk  may  now  be  given,  so  that  a  high-proteid 
milk,  rich  in  casein,  is  not  necessary.  As  it  is  desirable  to  con- 
tinue the  use  of  milk  at  this  age,  the  following  combination  of  top 
milk  and  water  may  be  used  instead  of  full  milk:  A  quart  bottle  of 
milk  is  allowed  to  stand  at  a  temperature  between  40°  and  50°F. 
for  five  hours,  after  which  the  top  10  ounces  are  removed  with  a 
Chapin  dipper.  (See  Fig.  4,  p.  57.)  The  10  ounces  of  top  milk  are 
mixed  with  20  ounces  of  oatmeal  gruel  or  plain  boiled  water  and  given 
as  a  drink. 

The  giving  of  high-fat  mixtures  in  constipation  is  sometimes  over- 
done even  in  feeding  older  children.  We  seldom  find  a  child  five 
years  of  age  who  can  digest,  day  after  day,  a  milk  or  cream  mixture 
containing  over  4  per  cent,  of  fat.  Attacks  of  acute  indigestion  and 
faulty  nutrition  are  very  apt  to  result  when  too  high  a  fat  is  persistently 
given.  In  not  a  few  instances  I  have  seen  grave  malnutrition  result 
from  an  attempt  to  relieve  the  constipation  by  high-fat  feeding.  It 
must  also  be  remembered  that  high-fat  mixtures,  if  given  to  children  of 
any  age,  may  produce  constipation,  with  hard,  very  light  colored,  and 
usually  foul-smelling  stools.  By  using  the  top  milk,  diluted,  we  give 
a  sufficient  amount  of  fat  and  relieve  the  constipation  by  removing  a 
considerable  percentage  of  the  casein,  the  usual  constipating  element, 
the  percentage  of  which  in  the  30  ounces  of  food,  above  referred  to,  is 
but  one-third  that  in  full  milk.  Of  course,  the  nutritive  value  of  the 
dilution  is  less  than  that  of  full  milk,  but  the  child  is  now  at  an  age  when 
proteid  can  be  given  in  other  forms  than  in  the  milk. 

Diet  After  the  Second  Year. — White  wheaten  bread,  wheaten  flour 
crackers,  with  full  raw  milk  should  form  no  part  of  the  dietary  of 
these  patients.  It  is  best  to  give  to  parents  of  children  we  are  treating 
for  constipation  a  list  of  permissible  articles  of  food  from  which 
suitable  meals  may  be  prepared.  The  following  articles  of  diet  may  be 
allowed : 

Animal  broths,  purees  of  peas,  Hashed  chicken, 

beans,  and  lentils.  Lamb  chops. 

Rare  roast  beef.  Soft-boiled  eggs. 

Rare  steak. 
Green  vegetables,  such  as: 

Peas.  Asparagus. 

String-beans.  Strained  stewed  tomatoes. 

Spinach.  Cauliflower,  mashed. 

Cereals,  as  follows  (each  cooked  for  three  hours) : 

Cracked  wheat.  Hominy. 

Oatmeal.  Corn-meal. 


CONSTIPATION  243 

The  cereals  may  be  served  with  a  small  amount  of  milk  and  sugar, 
or,  better,  with  butter  and  sugar. 

Bran  biscuits.  Zwieback. 

Oatmeal  crackers.  Whole  wheaten  bread. 

Graham  wafers. 
Desserts : 

Stewed  rhubarb.  Corn-starch. 

Stewed  or  baked  apple.  Plain  vanilla  ice-cream. 

Stewed  prunes.  Junket. 

Custard. 

Malted  milk  may  be  given  as  a  drink.  Six  teaspoonfuls  of  malted 
milk  in  8  ounces  of  hot  water  may  be  given  once  or  twice  daily.  An 
agreeable  change  in  the  taste  of  the  malted  milk  may  be  made  by  the 
addition  of  a  teaspoonful  of  cocoa.  If  milk  is  given  as  a  drink,  the 
top  10  ounces  from  a  quart  bottle  should  be  used  as  described  above, 
mixed  with  20  ounces  of  boiled  water  or  oatmeal  jelly. 

A  child  in  fair  health  after  the  second  year  usually  thrives  best 
on  three  meals  daily.  If  he  is  delicate,  or  if  a  fourth  meal  does  not 
interfere  with  the  appetite  for  the  other  meals,  it  may  be  allowed. 
The  extra  meal,  however,  should  be  light,  and  is  best  given  between 
2  and  3  o  'clock  in  the  afternoon.  For  a  child  suffering  from  constipa- 
tion, this  meal  may  consist  of  a  cup  of  broth  with  a  graham  or  oatmeal 
cracker.  Orange-juice  or  a  scraped  raw  apple  may  also  be  given  at 
this  time.  When  only  three  meals  are  allowed,  the  orange-juice  or 
scraped  apple  should  be  given  in  the  afternoon  about  two  hours  before 
the  evening  meal.  The  giving  of  the  fruit-juice  or  the  apple  on  an 
empty  stomach  is  a  valuable  aid  in  relieving  chronic  constipation. 
These  patients  should  also  be  encouraged  to  eat  plenty  of  butter.  The 
use  of  olive  oil  internally  is  of  as  much  service  here  as  in  treating  bottle  or 
nursing  babies.  From  2  to  3  teaspoonfuls  are  given  after  each  meal. 
Oil  is  usually  well  borne  by  the  stomach;  in  fact,  many  children  be- 
come very  fond  of  it.  Inasmuch  as  it  is  more  of  a  food  than  a 
medicine,  its  use  may  be  continued  for  months  if  necessary. 

Diet  After  the  Fifth  Year. — Permissible  articles  for  a  child  of  from 
five  to  ten  years  of  age  include  those  mentioned  above,  with  the 
addition  of  dates,  figs,  raw  and  cooked  fruits,  baked  and  stewed 
potatoes,  meats,  baked  and  broiled  poultry,  and  fish.  The  latter 
should  be  served  plain,  without  sauce.  Plain  puddings  may  also  be 
allowed.  One  or  two  raw  apples,  an  orange,  or  a  large  peach  or  pear 
should  be  given  every  afternoon.  It  is  not  promised  that  in  a  case  of 
chronic  constipation  the  above  diet  will  at  once  produce  normal  bowel 
movement.  The  diet  must  be  continued  for  weeks  in  some  cases  before 
marked  benefit  will  be  observed ;  in  others  the  results  are  very  prompt 
and  satisfactory. 

Local  Measures. — Enemata  and  suppositories  will  be  necessary  at 
first;  until  the  habit  of  an  evacuation  of  the  bowels  at  a  certain  time 


244  THE    PRACTICE    OF    PEDIATRICS 

every  daj^  is  established.     Such  measures,  however,  should  be  continued 
but  a  very  short  time. 

Drugs. — Drugs  may  be  of  temporary  service.  The  cascara  prepa- 
rations are  the  best  for  this  condition.  If  the  child  can  swallow  a 
pill  or  a  tablet,  the  drug  may  be  given  in  this  form.  The  1-grain 
tablets  of  cascara  may  be  ordered,  and  the  nurse  instructed  to  give 
from  one  to  three  or  four  at  bedtime.  If  the  drug  has  been  properly 
prepared  from  the  well-seasoned  bark,  a  reasonable  dose  will  occasion 
no  griping,  and  the  amount  given  on  succeeding  nights  may  be 
diminished  instead  of  increased,  as  is  often  necessary  with  many  other 
laxatives.  A  most  satisfactory  form  of  medication  in  my  hands  has 
been  the  following  combination : 

I^     Sodii  bicarbonatis 5ij 

Syr.  rhei  aromatici 

Fluidex.  cascarse  sagrada?  (aromatic) aa5ij 

M.  Sig. — J^  to  1  teaspoonful  after  each  meal. 

After  the  diet  and  habits  of  life  have  been  arranged,  the  mother 
or  nurse  is  instructed  to  give  the  prescription  three  times  daily  after 
meals,  in  sufficient  amount  to  produce  at  least  one  free  evacuation 
daily.  The  mixture  is  very  pleasant  to  the  taste  and  is  well  taken. 
As  its  administration  is  continued,  less  will  be  required,  but  it  is  to  be 
insisted  upon  that  the  medicine  be  given  three  times  daily,  even  though 
the  dosage  be  reduced  to  three  drops  at  a  time.  There  is  always  a 
temptation  on  the  part  of  those  in  charge  of  the  patient  to  give  one 
large  dose  at  bedtime.  The  results  are  not  as  satisfactory  when  this 
is  done.  In  a  vast  number  of  cases  I  have  been  able,  with  intelligent 
home  cooperation,  to  discontinue  the  medication  entirely  after  a  month 
or  two. 

Castor  oil,  calomel,  or  podophyllin  should  never  be  given  with- 
out other  indications  than  simple  constipation.  In  the  cases  in  which 
the  stools  are  soft,  but  difficult  of  passage  because  of  deficient  per- 
istalsis, the  tinctures  of  nux  vomica  and  belladonna  may  be  given  with 
benefit  if  continued  for  a  considerable  time.  A  child  three  years  of 
age  may  be  given  3  drops  of  the  tincture  of  nux  vomica  and  2  drops 
of  the  tincture  of  belladonna  3  times  daily  in  tablet,  capsule,  or  liquid 
form.  The  constipation  which  accompanies  mucous  colitis  is  referred 
to  under  that  heading.  The  liquid  albolene  (aromatic)  may  also  be 
used  in  these  patients.  A  large  dose  may  be  required  at  first — ■ 
perhaps  one  to  two  ounces  at  bedtime. 

Treatment  of  Obstinate  Constipation. — Children  who  resist  the 
above  method  of  treatment  after  several  months'  trial  may  be  classed 
with  those  who  have  some  considerable  intestinal  anomaly — usually 
an  elongated  and  often  displaced  sigmoid  (p.  208).  In  these,  daily  ab- 
dominal massage  by  a  skilled  person,  together  with  the  diet  suggested 
and  the  internal  use  of  liquid  albolene  will  prove  effective. 

INTESTINAL  OBSTRUCTION 

Agencies  impeding  or  preventing  the  normal  evacuation  of  the 
bowels  may  be  either  congenital — due  to  a  malformation  of  some  por- 


INTESTINAL   OBSTRUCTION  245 

tion  of  the  intestinal  tract — or  they  may  be  acquired.  Congenital 
malformation  may  be  found  in  any  portion  of  the  tract,  but  exists  most 
frequently  at  or  near  the  outlet,  or  in  the  region  of  the  duodenum. 
Silverman  states  that  42  per  cent,  of  the  cases  of  congenital  malforma- 
tion involve  the  duodenum.  Obstruction  at  the  outlet  of  the  bowel 
may  be  due  to  an  imperforate  anus,  or  the  absence  of,  or  atresia  of,  the 
lower  portion  of  the  rectum.  The  treatment  of  this  deformity  is 
surgical. 

The  most  common  cause  of  acquired  obstruction  is  intussusception 
(p.  233).  Peritonitis,  both  acute  and  chronic,  may  cause  a  cessation  of 
bowel  action.  Tuberculous  peritonitis,  through  the  formation  of 
fibrinous  bands  and  adhesions,  may  cause  sufficient  constriction  of  the 
gut  to  prevent  the  passage  of  the  intestinal  contents.  In  such  cases, 
also,  relief  is  best  furnished  by  surgical  measures. 

Acute  infective  peritonitis  (p.  256) ,  producing  a  complete  cessation 
of  peristalsis,  acts  indirectly  as  a  means  of  preventing  the  normal  pas- 
sage of  the  bowel  contents.  The  infection  is  usually  secondary. 
Operative  procedures  may  be  attempted,  but  all  my  cases  have  been 
fatal.  Two  underwent  operation,  as  it  was  feared  there  might  be  an 
intussusception  or  a  volvulus.  In  one  case  peritonitis  followed  pneu- 
monia, the  infection  being  due  to  the  pneumococcus. 

Strangulated  hernia  is  a  condition  by  no  means  difficult  of  diagnosis 
and  demands  prompt  surgical  relief. 

Intra-abdominal  tumors,  such  as  sarcoma  of  the  kidney  and  hydro- 
nephrosis, may  cause  obstruction  through  pressure  on  the  intestine. 

Illustrative  Cases. — Fecal  impaction  was  found  in  two  of  my  cases  of  intestinal 
obstruction.  Both  were  seen  in  consultation.  There  had  been  prolonged  con- 
stipation with  insufficient  evacuations,  owing  to  neglect  on  the  part  of  the  attend- 
ants. The  duration  of  the  condition  it  is  impossible  to  state,  as  the  children  were 
permitted  to  go  to  the  toilet  alone,  and  as  both  were  under  five  years  of  age,  but 
little  dependence  could  be  placed  upon  their  testimony.  In  both  cases  enemata 
and  cathartics  had  been  tried  in  vain.  There  was  vomiting  and  slight  abdominal 
distention.  There  was  no  fever  and  no  marked  tenderness  on  pressure.  In  my 
opinion,  the  vomiting  was  due  chiefly  to  the  medication,  for  it  ceased  when  drugs 
were  discontinued.  Both  children  responded  to  massage  and  injections  of  molasses 
and  water.  Eight  ounces  of  molasses  and  eight  ounces  of  water  were  introduced 
by  means  of  a  rectal  tube  at  intervals  of  four  hours.  One  case  was  relieved  after 
the  second  injection,  the  other  after  the  fourth.  Massage  was  early  brought  into 
use.  This  was  given  for  thirty  minutes  and  repeated  after  an  interval  of  ninety 
minutes.     The  interrupted  massage  was  continued  until  an  evacuation  occurred. 

An  unusual  case  of  intestinal  obstruction  was  seen  in  a  wretched,  premature 
infant,  five  months  of  age,  weighing  about  seven  pounds.  The  child  had  a  con- 
genital heart  lesion  and  deformities  of  the  ears.  He  was  suddenly  taken  ill  with 
vomiting,  and  the  passage  consisted  of  pale  mucus  streaked  with  blood.  No  tumor 
could  be  felt,  but  a  diagnosis  of  intussusception  was  made  and  the  abdomen  opened. 
At  the  site  of  the  obstruction  was  a  Meckel's  diverticulum  which  had  twisted  the 
gut  so  as  to  prevent  the  passage  of  gas  or  intestinal  contents. 

Paralytic  Ileus. — Two  infants  under  one  year  of  age,  ill  with 
severe  intestinal  toxemia,  developed  intestinal  obstruction  with  marked 
abdominal  distention.  Exploratory  abdominal  incision  in  one  and 
autopsy  in  the  other  failed  to  show  any  abnormality. 


246  THE    PKACTICE    OF    PEDIATEICS 

INTESTINAL  CYSTS  OR  DIVERTICULA  (CONGENITAL) 

A  most  unusual  case  of  intestinal  obstruction  recently  came  under 
my  care.  A  well-nourished,  breast-fed  child,  five  weeks  of  age,  became 
ill  with  what  appeared  to  be  intestinal  indigestion.  There  was  a  sUght 
elevation  of  the  temperature,  and  the  stools  were  green,  undigested, 
and  watery.  The  family  physician.  Dr.  Walter  Fleming  treated  the 
case  by  the  usual  methods.  An  improvement  in  the  stool  followed, 
but  a  marked  degree  of  tympanites  remained.  Feces  and  gas  were, 
however,  passed  in  small  amounts,  and  at  times  the  abdomen  was 
sufficiently  soft  to  allow  of  free  palpation.  The  tympanites  gradually 
increased,  and  instead  of  being  intermittent,  persisted.  About  one 
week  after  I  first  saw  the  case  it  came  under  my  immediate  supervision 
in  New  York  City. 

Feces  and  gas  were  passed  with  difiiculty — occasionally  there  was  a 
fairly  large  stool.  The  child  was  in  no  way  ill,  and  suffered  only  from 
the  abdominal  distention ;  when  this  was  relieved,  the  baby  took  food 
well  and  was  content.  In  spite  of  our  every  ejffort  in  regard  to  diet, 
medication,  local  measures  to  the  abdomen,  and  colonic  treatment,  the 
condition  of  tympanites  gradually  increased  and  became  permanent 
and  extreme. 

The  patient  was  sent,  at  about  the  sixth  day  imder  my  observation, 
to  the  Babies'  Hospital,  where  all  means  and  attempts  at  reduction  of 
the  gaseous  distention  were  likewise  futile. 

An  exploratory  incision  was  made  into  the  abdominal  wall  by  Dr. 
Wm.  A.  Downes,  who  discovered  a  tumor  in  the  cecum.  An  artificial 
anus  was  made  in  the  ileum  above  the  valve,  and  the  tympanites  was 
relieved;  but  the  child  died  shortly  from  exhaustion. 

A  postmortem  examination  showed  just  above  the  ileocecal  valve, 
and  within  5  cm.  of  it,  a  round,  sessile  cyst,  3  cm.  long  and  2.5  wide  by 
0.75  cm.  high,  the  mucosa  over  it  thin,  stretched,  congested  at  either 
side,  pale  on  top,  with  dilated  vessels  from  the  base  radiating  over  the 
sides  and  top.  Immediately  beyond  was  a  second  cyst,  2.5  x  2.5  cm. 
and  only  0.25  high;  close  to  it,  almost  bilocular,  was  a  third,  2.5  x  2 
and  0.75  cm.  high.  Contents  showed  mucolymph  within  a  smooth 
lining.  Between  the  mucosa  and  submucosa  the  muscle  was  normal. 
Next  to  the  last  cyst  was  a  part  of  a  Peyer's  patch,  mucosa  congested, 
walls  thickened  and  edematous.     The  colon  was  congested. 

The  cysts  or  diverticula  had  encroached  upon  the  lumen  of  the  gut, 
and  because  of  their  proximity,  formed  a  sufficient  obstruction  to  pre- 
clude the  passage  of  gas  and  the  intestinal  contents.  Evidently  the 
later  growth  of  the  cysts  was  quite  rapid,  as  the  obstruction  caused 
symptoms  increasing  only  gradually  in  severity,  and  permitted  of  the 
passage  of  feces  until  a  day  or  two  before  the  operation. 

Blackader,  of  Montreal,  reported  a  similar  case  before  the  American 
Pediatric  Society  in  June,  1913.  He  was  able  to  find  records  of  but 
three  other  cases  of  congenital  intestinal  cysts  in  the  literature.  The 
condition,  according  to  Gant,  is  not  uncommon  in  adults;  and  in  them 


THE  INTESTINAL  PARASITES  247 

the  cysts  are  usually  found  in  the  sigmoid  and  colon  and  are  looked 
upon  as  acquired. 

THE  INTESTINAL  PARASITES 

The  most  common  of  the  intestinal  parasites  found  in  children  are 
Ascaris  lumbricoides,  or  round-worm,  Oxyuris  vermicularis,  or  thread- 
worm, Tienia,  or  tape-worm,  and  Uncinaria,  or  hook-worm. 

The  Blood  in  Infections  by  Intestinal  Parasites. — Patients  with 
teniasis  or  uncinariasis  frequently  "present  a  pronounced  degree  of  ane- 
mia of  the  chlorotic  type.  In  occasional  cases  of  tape-worm  infection 
the  blood-picture  resembles  that  of  actual  pernicious  anemia.  Where 
uncinariasis  is  prevalent  and  the  inhabitants  are  subject  to  constant 
infection  from  the  soil,  such  terms  as  "Egyptian  chlorosis,"  "miner's 
anemia,"  and  "  brickmaker's  anemia"  are  current  synonyms  for  the 
disease. 

Leukocytosis  in  the  parasitic  infections  is  not  characteristic,  but 
may  occur  during  the  acute  stage  of  trichiniasis.  Eosinophilia,  how- 
ever, is  a  very  characteristic  manifestation  of  reaction  to  the  parasitic 
toxins,  and  in  trichiniasis  often  attains  a  degree  of  20  to  50  per  cent. 
Stiles  reports  that  in  uncinariasis  the  chronic  cases  with  poor  resistance 
show  little  eosinophilia,  while  those  undergoing  improvement  under 
treatment  afford  counts  averaging  as  high  as  13.2  per  cent.* 

Ascaris  Lumbricoides  (Round- worm). — This  parasite  is  a  very  fre- 
quent inhabitant  of  the  small  intestine.  The  worm  is  5  to  10  inches 
long,  cylindric  in  form,  and  closely  resembles  an  ordinary  earth-worm. 
Large  numbers  may  exist  in  the  same  patient,  and  have  been  known  to 
cause  serious  secondary  symptoms,  such  as  obstruction  of  the  bile- 
duct  or  a  severe  attack  of  choking,  induced  by  the  migration  of  the 
worms  from  the  esophagus  into  the  larynx.  They  have  been  known  to 
invade  the  Eustachian  tube.  The  ova  are  taken  into  the  digestive 
tract  in  uncooked  food  and  occasionally  in  drinking-water.  The  eggs 
are  of  oval  form,  and  when  present  in  the  feces,  may  be  distinguished 
by  their  thick  shells  and  "  mammillated "  borders  and  by  the  absence 
of  segmentation. 

Symptoms. — The  round-worms,  if  in  considerable  number,  may 
produce  colic  or  constipation,  the  latter  oftentimes  alternating  with 
diarrhea.  Nervous  disturbances  of  an  urgent  character  are  not  un- 
common. In  the  great  majority  of  my  cases,  however,  no  symptom 
whatever  was  present,  and  the  fact  that  the  child  had  parasites  in  the 
intestine  was  first  learned  when  a  worm  was  found  to  have  been  passed 
by  the  rectum.  In  the  case  of  one  of  my  patients,  three  years  of 
age,  there  were  repeated  convulsions.  The  mother  stated  that  the 
child  had  passed  a  couple  of  round-worms  the  day  before.  I  gave  one 
ounce  of  castor  oil,  and  after  an  hour,  two  grains  of  santonin.  Forty- 
three  large  round-worms  were  passed  during  the  next  twenty-four 
hours.  This  is  the  largest  number  I  have  known  to  come  from  one 
child.     The  round-worm  is  rare  in  New  York  City  children.     I  have 

*  Osier's  Modern  Medicine,  vol.  i. 


248  THE    PRACTICE    OF    PEDIATRICS 

seen  but  five  cases.     In  children  who  hve  in  the  country  it  is  of  fairly 
common  occurrence. 

Treatment. — At  bedtime  I  order  from  2  to  4  teaspoonfuls  of  castor 
oil.  Early  the  following  morning,  about  two  hours  before  breakfast, 
santonin  is  given.  To  children  under  two  years  of  age  I  give  1  grain; 
to  those  from  two  to  four  years  of  age,  l}y^  grains;  and  after  the  fourth 
year,  2  grains.  The  santonin  is  prescribed  in  a  powder  or  capsule, 
with  an  equal  quantity  of  sugar-of-milk.  If  the  passage  of  worms 
follows  its  use,  the  treatment  is  repeated  in  three  days;  and  again  in  a 
week,  if  worms  are  passed  after  the  second  treatment. 

Oxyuris  Vermicularis  (Thread -worm  or  Pin-worm). — Thread- 
worms are  of  more  frequent  occurrence  in  city  children  than  are  either 
round-worms  or  tape- worms.  The  thread-worms  have  their  habitat  in 
the  lower  portion  of  the  colon,  where  they  become  attached  to  the 
mucosa,  and  occasionally  produce  considerable  catarrhal  inflammation. 
The  oxyuris  is  an  insignificant  looking  object,  light  in  color,  from  3-^ 
to  '^i  inch  in  length,  and  of  the  diameter  of  a  pin.  The  ova  are  not  so 
large  as  those  of  the  ascaris.  Raw  fruit  and  uncooked  vegetables  may 
convey  the  infection. 

Symptoms. — The  worms  produce  an  irritation  and  itching  about, 
and  a  pricking  sensation  within,  the  anus.  The  discomfort  is  bitterly 
complained  of  after  the  child  is  in  bed  at  night,  the  parasites  being 
particularly  active  at  this  time.  If  there  is  any  doubt  as  to  their 
presence,  the  patient  should  receive  a  full  dose  of  castor-oil — at  least 
two  teaspoonfuls.  The  discharges  should  be  kept  for  inspection. 
If  the  parasites  are  present,  they  will  usually  be  found  embedded  in  a 
considerable  quantity  of  mucus,  in  the  form  of  pieces  resembhng  white 
thread  from  }i  to  3^^  inch  in  length. 

Treatment. — Santonin,  recommended  by  some  writers  as  of  service 
in  these  cases,  has  been  without  the  slightest  value  in  my  hands.  In 
fact,  the  use  of  drugs  of  any  kind  seems  to  be  of  very  little  value.  After 
the  third  year  turpentine  in  one-drop  doses  after  meals  is  probably 
the  most  valuable  form  of  internal  medication.  It  may  be  given  in 
emulsion  or  dropped  upon  sugar. 

Rectal  Injections.^ — Local  treatment  with  the  infusions  of  garlic 
or  quassia  is  our  principal  reliance  in  the  management  of  the  obsti- 
nate cases.  In  patients  in  whom  the  worms  have  existed  for  a  con- 
siderable time  the  resulting  irritation  causes  a  profuse  secretion  of 
mucus  in  the  descending  colon  and  sigmoid.  This  mucus  must  be 
washed  out  before  any  direct  treatment  can  be  effective.  The  colon 
should  first  be  irrigated  with  a  solution  of  one  tablespoonful  of  borax 
to  a  pint  of  water.  For  this  purpose  a  No.  18  American  catheter  should 
be  used,  as  in  colon  flushings.  The  tube  should  be  introduced  at 
least  10  inches.  The  child  should  be  encouraged  to  bear  down  and 
expel  the  water  alongside  the  tube,  no  attempt  being  made  to  have  the 
solution  retained.  After  the  preliminary  washing  is  complete,  eight 
ounces  of  the  infusion  of  quassia  may  be  passed  into  the  colon.  To 
facilitate  retention  of  the  fluid  the  tube  must  be  quickly  withdrawn. 


THE    INTESTINAL    PARASITES  249 

The  child  may  then  be  placed  on  the  left  side,  with  the  buttocks  elevated 
on  a  pillow.  This  position,  or  at  least  the  recumbent  position,  should 
be  maintained  for  one  half -hour  after  the  injection  is  given.  A  solution 
of  the  bichlorid  of  mercury  1 :  10,000  may  be  used  in  the  same  way. 
For  ordinary  family  use,  however,  I  consider  either  the  garlic  or  the 
quassia  much  safer  and  equally  effective.  Garlic  used  in  infusion 
identical  with  quassia  is  particularly  effective,  but  its  very  disagreeable 
odor  makes  its  use  objectionable  in  many  households,  and  therefore  I 
advise  it  only  when  other  means  fail.  After  the  worms  and  all  evidences 
of  their  presence  disappear,  the  treatment  should  be  continued  for  a 
time  on  alternate  days,  and  then  twice  a  week,  gradually  reducing  the 
frequency  of  the  irrigations  until  they  are  no  longer  required.  Few 
cases  recover  in  less  than  four  weeks,  and  in  many  it  will  be  found 
necessary  to  continue  the  treatment  for  months.  I  have  never  seen  a 
case,  however,  which  did  not  eventually  respond  to  persistent 
treatment. 

Tenia  or  Tape-worm. — The  tape- worm  is  along,  flattened  organism, 
consisting  of  a  head  or  scolex  and  hundreds  of  individual  proglottides 
or  offshoots  derived  from  the  head.  Each  segment  in  the  series  contains 
a  large  number  of  eggs.  After  the  discharge  of  the  segments  from  the 
body  these  ova  are  ingested  and  undergo  a  period  of  development  in 
the  tissues  of  an  intermediate  host,  eventually  forming  the  cysticerci 
or  encapsulated  bladder- worms  which  give  the  "measle"  appearance 
to  infected  meat.  This  meat,  when  insufficiently  cooked,  conveys 
the  cysticercus  to  the  stomach  of  the  patient,  where  the  digestive 
juices  liberate  from  the  cyst-wall  a  head  which  is  capable  of  becoming 
attached  to  the  mucosa  of  the  child 's  alimentary  tract  and  producing 
a  mature  parasite. 

The  chief  varieties  of  tape-worm  are  the  Taenia  saginata,  or  beef- 
worm,  the  Taenia  solium,  or  pork-worm,  the  Bothriocephalus  latus,  an 
inhabitant  of  fish,  and  the  Taenia  elliptica,  which  passes  an  intermediate 
stage  in  the  vermin  of  household  pets. 

The  Taenia  saginata  attains  a  length  of  from  ]  2  to  20  feet.  The 
head  is  from'  1  to  2  mm.  in  diameter,  and  contains  four  suckers,  but  no 
hooklets. 

The  Taenia  solium  is  rarely  over  12  feet  long.  The  offshoots  from 
the  median  canal  forming  the  uterus  of  a  segment  show  less  branching 
than  in  the  case  of  Taenia  saginata,  and  the  developed  segments  in 
Taenia  solium  are  more  nearly  square.  The  head  has  a  short  rostellum 
with  a  circle  of  hooklets. 

The  Bothriocephalus  latus  is  far  more  common  in  northern  Europe 
than  in  America.  When  mature,  this  worm  is  over  25  feet  long.  The 
segments  are  unusually  broad,  and  the  head  is  oval  in  outline  and 
contains  two  lateral  grooves. 

Taenia  elliptica  occurs  occasionally  in  very  young  infants.  It  is 
only  6  to  12  inches  in  length,  and  its  segments  are  long  and  narrow. 

Symptoms. — The  tape-worm  may  produce  symptoms  of  disturbed 
intestinal    digestion,   such    as  colicky  pain  and   diarrhea.     Usually, 


250  THE    PRACTICE    OF    PEDIATRICS 

however,  the  first  warning  that  the  child  is  affected  is  afforded  by  the 
passage  of  segments  of  the  worm,  ,      i 

A  worm  14  feet  in  length  was  expelled,  after  treatment,  by  a  little 
girl  four  years  old.  There  had  never  been  a  symptom  of  its  presence 
other  than  the  passage  of  several  of  the  segments. 

A  child,  eighteen  months  of  age,  under  my  care,  has  passed  18  feet 
of  a  tape-worm  without  dislodging  the  head. 

Treat7nent.-^ At  bedtime,  }i  ounce  to  1  ounce  of  castor  oil  is  given. 
Early  next  morning,  two  hours  before  breakfast,  3^^  dramof  theoleoresin 
of  male-fern  (aspidium),  in  emulsion  or  in  capsule,  is  given.  During 
the  day  a  light  fluid  diet  only  is  allowed,  such  as  broth,  gruel,  and  fruit- 
juices.  One  treatment  with  a  good  preparation  of  the  male-fern  will 
usually  bring  away  the  worm  entire.  The  head  should  be  care- 
fully searched  for  with  the  magnifying-glass.  If  the  head  is  not  found, 
the  treatment  should  be  repeated  after  an  interval  of  twenty-four 
hours. 

Uncinaria;  Hook-worm.— The  two  forms  of  this  parasite,  Aw- 
kylostoma  duodenale  and  Uncinaria  americana,  exhibit  certain  morpho- 
logic differences,  the  most  marked  of  which  is  the  existence,  in  anky- 
lostoma,  of  two  pairs  of  ventral,  hook-like  teeth,  which  are  not  present 
in  the  American  species.  The  hook-worm  measures  from  3^  to  ^:^  inch 
in  length.  The  ova,  in  large  numbers,  are  present  in  the  feces,  and 
may  be  recognized  as  small  oval  bodies,  usually  clear  in  appearance, 
about  50  At  X  30  At  in  size,  showing  various  stages  of  segmentation. 
After  the  administration  of  thymol,  followed  by  a  saline  cathartic, 
the  worms  themselves  may  appear  in  the  stools  as  small  objects,  a  little 
thicker  than  a  pin,  about  }i  inch  long,  and  with  the  characteristic, 
retroverted  hooked  end. 

The  hook-worm  has  been  known  for  many  generations,  but  only 
during  the  past  ten  years  has  uncinariasis  received  due  attention. 
In  certain  localities — notably  the  West  Indies  and  the  Southern  States 
— the  soil  is  very  generally  infected,  and  a  considerable  proportion  of 
the  population  harbor  the  parasites.  These  not  only  remove  blood 
from  the  circulation  of  the  victim,  but  elaborate  a  toxin  which  is  thought 
to  assist  in  the  causation  of  the  significant  anemia  of  this  disease.  In- 
fection usually  takes  place  from  the  soil,  through  the  skin  of  bare  feet. 
Infection  may  also  take  place  through  the  skin  of  the  hands,  or  by 
means  of  the  gastro-intestinal  tract,  through  the  use  of  raw  fruit  or 
vegetables. 

Symptoms. — The  symptoms  are  those  of  digestive  disturbance 
combined  with  progressive  anemia.  The  anemia  is  often  of  an  extreme 
degree.  Abdominal  discomfort  of  considerable  degree  may  exist 
and  this  possibly  gives  rise  to  the  curious  habit  of  earth-eating,  which 
these  patients  may  acquire  in  their  desire  for  the  relief  which  the 
ingestion  of  food  usually  affords.  Stiles  reports  a  case  in  which  a  boy 
ate  three  coats,  thread  by  thread,  in  twelve  months.  As  the  disease 
progresses,  the  face  and  ankles  may  become  edematous.  The  stools 
contain  occult  blood.    Lassitude  and  incapacity  for  sustained  effort 


THE    INTESTINAL    PARASITES  251 

are  prominent  symptoms,  and  unless  the  cause  of  the  disease  is  elimi- 
nated, the  child  falls  behind  in  physical  and  mental  development. 

Treatment. — Thymol  is  specific  for  the  hook-worm.  A  purgative 
should  precede  the  administration  of  the  drug.  Twelve  hours  before 
administering  the  thymol  a  full  dose  of  cascara  sagrada  or  epsom  salts 
should  be  given.  The  thymol  should  be  given  in  solid  form,  5  to  10  grains 
every  three  hours  until  four  doses  have  been  given.  The  drug  is  best 
given  in  capsules  or  pills.  Twelve  hours  after  the  last  dose,  a  saline 
cathartic  should  be  administered.  Ten  days  after  the  administration 
of  the  thymol  the  stools  should  again  be  examined  for  the  ova  of  the 
parasite,  and  if  ova  are  found,  the  treatment  should  be  repeated. 
Thymol  poisoning  is  indicated  by  dizziness  and  discoloration  of  the  urine. 
When  these  symptoms  appear,  the  treatment  should  be  discontinued 
and  further  purgation  brought  into  use.  During  the  active  treatment 
the  diet  should  consist  of  milk,  broths,  and  gruels. 

The  anemia  and  malnutrition  should  be  managed  along  the  lines 
suggested  under  the  respective  headings. 

Trichiniasis  is  a  disease  which  children  may  occasionally  acquire 
from  the  eating  of  uncooked  ham,  sausage,  or  pork.  In  localities  where 
meat  inspection  is  rigid,  cases  of  this  infection  are  relatively  rare. 
The  Trichina  spiralis  (Trichenella  spiralis)  is  not  infrequently  found 
in  hogs.  The  female  parasite  deposits  larvse  in  the  submucosa,  whence 
they  are  carried  by  the  lymphatics  to  the  blood-stream,  and  on  reaching 
the  voluntary  muscles,  become  encapsulated.  When  the  uncooked, 
infected  meat  is  eaten,  the  capsules  undergo  dissolution,  and  the  con- 
tained trichinae  are  liberated  in  the  digestive  tract  of  the  patient.  The 
forms  attain  full  development  in  the  small  intestine,  and  about  a  week 
after  the  ingestion  of  the  meat  set  free  a  new  brood  of  embryos. 

Van  Cott  and  Lind*  found  the  trichina  spiralis  in  the  cerebro- 
spinal fluid.  These  findings  have  since  been  confirmed  by  Young, 
Cummins  and  others.  In  doubtful  cases  an  examination  of  the  cerebro- 
spinal fluid  supplies  a  possible  medium  for  the  confirmation  of  a 
diagnosis. 

Symptoms. — The  severe  symptoms  of  trichiniasis  develop  about 
ten  days  after  the  eating  of  the  infected  meat,  frequently  following 
a  period  of  preliminary  gastro-intestinal  disturbance.  When  well 
advanced,  the  disease  may  be  mistaken  for  typhoid,  malaria,  influenza, 
or  acute  rheumatism.  Fever  of  a  remittent  type,  great  muscular  pain 
and  soreness,  and  edema  of  the  face  and  eyelids  suggestive  of  nephritis 
are  the  more  pronounced  effects.  The  blood  shows  not  only  leukocyto- 
sis, but  a  marked  grade  of  eosinophilia.  The  symptoms  usually  subside 
after  a  week  or  ten  days.  Romanowitch  has  shown  that  in  traversing 
the  intestinal  mucosa  the  trichina  deposits  bacteria  which  may  dis- 
tribute secondary  infections.  How  important  this  fact  may  be  in  the 
explanation  of  symptoms  occurring  in  this  disease  remains  to  be  de- 
termined. In  doubtful  cases  trichiniasis  may  be  diagnosed  by  the  mi- 
croscopic demonstration  of  the  encapsulated  parasites  in  a  bit  of  muscle 
*  Journal  A.  M.  A.,  vol.  Ixvi,  No.  xxiv. 


252  THE    PRACTICE    OF    PEDIATRICS 

tissue  removed  under  local  anesthesia  from  the  deltoid,  biceps,   or 
gastrocnemius  of  the  patient. 

Illustrative  Case. — A  girl  eight  years  of  age  consulted  me  because  of  muscle 
soreness,  edema  of  the  skin,  and  especially  marked  swelling  and  stiffness  of  the 
muscles  of  the  left  leg.  Trichiniasis  was  suspected,  and  a  small  portion  of  the 
deltoid  was  removed,  which  showed  the  encapsulated  parasite. 

Treatment. — At  the  outset  of  the  disease  thorough  catharsis  is  of 
unquestionable  value,  for  it  has  been  estimated  that  "each  female 
parasite  removed  from  the  intestine  means  a  reduction  of  the  muscu- 
lar infection  by  from  1500  to  several  thousand  worms."*  Calomel 
is  undoubtedly  indicated  for  this  purpose,  and  this  drug  should  be 
given  in  doses  aggregating  1  to  2  grains,  accompanied  by  10  to  20 
grains  of  bicarbonate  of  soda,  and  followed  after  six  hours  by  a  saline 
cathartic.  Thymol  may  be  given  in  the  manner  suggested  under 
treatment  of  uncinariasis,  but  the  position  of  the  parasites  deep  in 
the  intestinal  mucosa  renders  most  of  them  secure  from  the  action 
of  an  anthelmintic.  After  the  disease  has  become  established,  the  treat- 
ment is  solely  symptomatic,  consisting  in  the  use  of  means  to  relieve 
pain,  control  temperature,  and  support  the  pulse,  which  in  severe 
infections  may  become  weak. 

APPENDICITIS 

The  Appendix.! — This  organ,  normally,  is  located  in  the  right 
iliac  fossa,  subjacent  to  McBurney's  point,  which  marks  the  junction 
of  the  two  lower  thirds  of  a  line  connecting  the  right  anterior  su- 
perior iliac  spine  with  the  umbilicus.  This  position  is  attained  as 
the  result  of  intra-uterine  changes  in  the  intestinal  canal,  involving 
a  gradual  migration  of  the  ileocolic  junction  from  a  primary  position 
in  the  left  iliac  fossa  upward  to  the  right,  beneath  the  liver,  and  finally 
downward  into  the  right  iliac  fossa.  When  these  changes  are  not  com- 
pleted, the  organ  will  not  be  found  in  its  normal  adult  location,  but 
frequently  higher  up.  Because  of  variations  in  development  the  ap- 
pendix may  or  may  not  have  its  origin  from  the  extreme  lower  portion 
of  the  cecum.  The  lumen  of  the  appendix  at  its  base  is,  moreover, 
often  very  minute.  Both  of  these  facts  partially  explain  the  liability  to 
inflammation.  The  total  diameter  of  the  organ  is  about  3^  inch,  and 
the  length,  which  is  extremely  variable,  is  usually  between  2  and  3 
inches.  Various  abnormalities  in  shape  and  direction  occur,  chiefly 
as  a  result  of  peritoneal  adhesions. 

The  appendix  contains  serous,  muscular  submucous,  and  mucous 
layers.  It  is,  however,  essentially  a  lymphoid  structure,  well  deserving 
the  name  "abdominal  tonsil."  Like  the  tonsil,  it  attains  its  maximum 
development  early  in  life,  and,  with  the  occurrence  of  the  atrophic 
changes  common  in  later  years,  shows  a  diminished  susceptibility  to 
mfection. 

Appendicitis  is  not  so  rare  a  disease  of  early  childhood  as  is  usually 

*  C.  W.  Stiles:  Osier's  Modern  Medicine,  vol.  i. 

t  Vide:  "Anatomy  and  Physiology  of  the  Appendix,"  by  Dr.  Andrew  McCosh, 
in  "American  Practice  of  Surgery,"  Bryant  and  Buck,  vol.  vii,  p.  618  et  seq. 


APPENDICITIS  253 

taught.  It  occurs  with  sufficient  frequency  for  the  practitioner  not 
to  forget  the  possibihties  of  its  unexpected  development. 

I  am  confident  that  both  acute  and  chronic  cases  are  often  over- 
looked because  of  the  difficulty  in  diagnosis.  In  describing  appendicitis, 
writers  are  inclined  to  divide  the  disease  into  types  such  as  catarrhal, 
suppurative,  gangrenous,  and  perforative.  Such  division  is  hardly 
possible.  Because  of  the  excess  of  lymphoid  tissue  in  the  child 's  ap- 
pendix, the  pathogenic  process  may  be  extremely  active,  and  a  case 
that  is  catarrhal  today  may  be  gangrenous  tomorrow.  Not  all  ca- 
tarrhal cases  go  on  to  the  later  stages.  Nevertheless,  it  must  always  be 
remembered  that  appendicitis  in  the  child  is  usually  a  much  more  ac- 
tive disease  than  in  the  adult. 

Age. — No  age  appears  to  be  exempt.  My  youngest  patient  was 
nine  months  of  age.  Shaw  reported  the  case  of  a  patient  seven  weeks 
of  age.  My  own  cases  have  been  in  children  ranging  from  nine 
months  to  fourteen  years. 

Symptoms. — That  many  errors  are  made  in  the  diagnosis  of  ap- 
pendicitis in  infants  and  young  children  is  beyond  doubt  for  the 
reason  that  the  cardinal  symptoms,  as  laid  down  by  writers,  viz., 
vomiting,  colic,  and  sensitiveness  to  pressure,  do  not  complete  the 
symptomatology.  Pain  is  a  relative  term,  and  the  complaint  of  pain, 
while  it  must  be  respected,  is  never  to  be  relied  upon.  Some  children 
will  exaggerate  the  sensitiveness  of  the  abdomen  to  pressure,  and  others 
will  deny  the  existence  of  pain  actually  present.  Vomiting  and  colic 
are  very  unreliable  signs.  Fortunately  in  children  one  sign  is  almost 
invariably  present  unless  there  is  a  malformed  or  misplaced  appendix, 
which  is  most  unusual.  The  sign  of  real  value  indicating  an  involved 
appendix  in  a  child  is  localized  muscle  rigidity — a  spastic  right  rectus. 
This  symptom  is  entirely  beyond  the  child 's  control,  and  while  young 
children  may  be  difficult  to  approach,  patience  in  gaining  the  child 's 
confidence,  combined  with  attempts  at  diversion,  will  make  a  satis- 
factory examination  possible. 

Deep  pressure  is  not  necessary.  If  both  recti  are  persistently 
rigid,  as  I  have  seen  in  a  few  cases,  the  fact  in  no  way  disproves  the 
presence  of  a  diseased  appendix.  The  signs  usually  given — vomiting, 
pain,  and  colic — are  corroborative  when  there  is  a  spastic  right  rectus. 
Alone  they  are  suggestive  of  appendicular  disease  in  children,  but  not 
diagnostic. 

With  the  rigidity  and  unusual  sensitiveness  to  deep  pressure,  there 
is  a  tendency  to  flexion  of  the  thigh  on  the  abdomen,  to  relieve  the 
tension  of  the  abdominal  muscles. 

Atypical  cases  may  be  seen,  and  in  my  experience  have  always  been 
due  to  an  abnormally  long  appendix.  Thus,  in  the  case  of  a  boy  of 
twelve  years,  the  appendix  was  6  inches  long  and  the  abscess  was 
located  in  the  tip,  which  was  in  the  right  hypochondrium.  In  this 
case  there  was  general  muscle  rigidity. 

In  an  eight-year-old  child  the  diseased  appendix  was  situated 
deeply  in  the  pelvis.     There  was  no  pain  or  rigidity.     Appendicitis  was 


254  THE    PRACTICE    OF    PEDIATRICS 

not  diagnosed  until  rupture  occurred  and  an  acute  localized  perit- 
onitis developed. 

In  another  child,  with  a  very  long  appendix,  the  local  symptoms 
were  all  referred  to  the  left  side.  Operation  was  delayed,  through  no 
fault  of  mine,  until  abscess  and  peritonitis  developed.  The  tip  of  the 
gangrenous  appendix  was  located  two  inches  to  the  left  of  the  median 
line. 

Leukocytosis. — A  leukocytosis  has  been  present  in  all  my  cases, 
the  differential  count  showing  70  per  cent,  or  over  of  polymorphonuclear 
cells. 

Exploratory  Incision. — After  a  considerable  experience  with 
obscure  acute  and  chronic  abdominal  conditions  in  children  I  have 
learned  that  an  exploratory  incision  should  be  made  as  soon  as  we 
realize  we  are  not  positive  regarding  the  character  of  the  trouble  at 
hand.     This  has  been  learned  through  experiences  which  I   regret. 

Prognosis. — The  prognosis  depends  upon  the  ability  of  the  physician 
to  diagnose  the  disease,  his  courage  to  act  promptly,  and  the  good 
sense  of  the  family.  In  the  young,  appendicitis  is  usually  of  the  ful- 
minating type,  and  while  temporizing  may  answer  in  the  adult,  it  may 
be  fatal  in  the  child.  Statistics  of  high  mortality  mean  defective  man- 
agement. In  children  over  two  years  of  age  the  results  should  be  as 
favorable  as  in  adults.  If  one  uses  ice-bags,  stupes,  and  salines  for 
three  or  four  days  and  then  operates,  there  will  be  a  large  mortality. 

Diagnosis. — The  chief  diagnostic  symptom  is  rigidity  of  the  abdomi- 
nal muscles,  usually  localized  in  the  right  side,  sometimes  general. 
I  have  seen  marked  general  rigidity  in  a  girl  eleven  years  of  age,  in 
whom  the  appendix  had  not  perforated.  This  symptom,  with  localized 
tenderness  and  the  presence  of  a  tumor,  is  to  be  looked  upon  as  an 
independent  diagnostic  sign.  All  other  symptoms  to  which  much 
importance  is  attached  are  only  of  corroborative  value. 

Differential  Diagnosis. — In  cases  of  intussusception  and  periodic 
vomiting  there  is  no  muscle  rigidity,  and  in  periodic  vomiting,  no  local- 
ized tenderness. 

Acute  peritonitis  may  simulate  a  later  stage  of  atypical  appendicitis 
so  closely  that  a  differential  diagnosis  is  impossible  without  an  explora- 
tory incision.  This  should  always  be  done  in  either  event,  whether 
there  is  a  pyogenic  peritonitis  or  peritonitis  due  to  intussusception. 

Acute  pneumonia  at  the  right  base,  with  pleurisy,  may  produce 
signs  closely  simulating  appendicitis,  and  is  one  of  the  conditions  that 
may  produce  a  spasm  of  the  right  rectus. 

With  pneumonia  and  pleurisy  there  are  the  unmistakable  physical 
signs,  the  respiratory  grunt,  high  temperature,  and  usually  cough,  to- 
gether with  the  objective  sign  of  rapid  breathing — signs  ordinarily 
sufficient  to  eliminate  an  error  in  diagnosis.  In  cases  in  which  the 
physician  feels  that  a  differentiation  is  impossible  the  x-ray  may  be 
brought  into  use  to  clear  up  the  situation. 

Treatment. — The  treatment  of  proved  acute  appendicitis  in  chil- 
dren demands  operation  as  early  as  possible.     For  the  borderland  case, 


CHRONIC    APPENDICITIS  255 

with  mild  symptoms  in  which  a  positive  diagnosis  is  not  possible,  rest 
in  bed,  a  fluid  diet  without  milk,  and  the  ice-bag  comprise  the  essentials 
in  a  scheme  of  treatment  which  may  suffice.  The  recumbent  posi- 
tion and  quiet  should  be  maintained  until  every  sign  of  the  trouble  has 
disappeared. 

Interval  Operation. — In  the  event  of  the  child's  recovering  from  a 
well-defined  attack  without  operation  a  suitable  time  should  be  selected 
for  an  interval  operation.  A  second  attack  is  very  liable  to  follow 
in  less  than  a  year,  with  a  strong  probability  of  abscess  formation. 
Furthermore,  we  cannot  time  the  subsequent  attacks,  and  these  may 
occur  with  great  severity  when  the  child  is  otherwise  ill  or  away  from 
home  where  necessary  surgical  skill  may  not  be  obtainable. 

CHRONIC  APPENDICITIS 

Chronic  appendicitis  has  a  very  decided  entity.  It  occurs  in  older 
children.  I  have  never  seen  a  case  before  the  fourth  year.  In 
pediatric  consultation  practice  it  is  not  unusual  to  find  the  condition 
after  this  period. 

Symptoms. — The  cases  usually  show  one  or  two  groups  of  symptoms. 
Two  cases  show  symptoms  of  both  types. 

A  child  in  apparent  health  has  complained  of  frequent  abdominal 
pain  over  a  period  of  several  months.  If  asked  to  place  his  hand  over 
the  painful  area,  he  will  almost  always  place  it  over  the  umbilicus. 
There  is  no  apparent  sensitiveness  over  the  appendix,  no  pain  on  deep 
pressure,  and  no  rigidity  of  the  recti.  The  pain  is  rarely  severe  and 
may  occur  at  considerable  intervals.  In  some  cases  the  abdomen  will 
never  feel  quite  comfortable.  There  may  be  diarrhea  alternating  with 
constipation,  or  the  stool  may  be  perfectly  normal  and  regular.  In 
others  unwarranted  attacks  of  acute  intestinal  indigestion  may  occur, 
the  occasion  of  which  will  not  be  explained  by  the  habits  of  the  patient. 

The  other  type  of  case  shows  periodic,  acute  manifestations.  These 
include  vomiting,  fever,  and  colicky  pains,  with  diarrhea.  There  may 
be  two  or  more  attacks  during  the  year.  As  in  the  cases  of  the  first 
type,  there  may  be  no  localization  of  signs  in  the  abdomen. 

Periodic  or  recurrent  intestinal  disturbances — so-called  indigestion 
— that  is  not  relieved  by  a  rational  life  and  careful  feeding  will  usually 
be  found  due  to  either  an  elongated  sigmoid  (p.  208)  or  to  a  chronic 
appendicitis. 

Comby  believes  that  many  cases  of  cyclic  vomiting  have  their 
origin  in  chronic  appendicitis,  and  he  claims  to  have  cured  a  considerable 
number  of  such  cases  by  removal  of  the  appendix. 

Treatment. — Suspicious  cases  should  be  given  an  anesthetic 
after  fasting  for  twelve  hours,  and  then  examined  by  deep  palpation 
and  through  the  rectum.  If  tumefaction  is  found  in  the  right  iliac 
fossa,  operation  for  the  removal  of  the  appendix  should  be  performed 
at  the  convenience  of  the  patient. 

A  badly  diseased  appendix,  as  large  as  an  adult  index-finger,  was 


256  THE    PRACTICE    OF    PEDIATRICS 

recently  removed  from  a  fourteen-year-old  patient  in  whom  there  had 
been  no  localized  symptoms  other  than  a  feehng  of  pressure  or  weight 
in  the  right  side,  but  who  always  had,  as  he  expressed  it,  an  uncomfort- 
able abdomen. 

ACUTE  GENERAL  PERITONITIS 

Acute -general  suppurative  peritonitis  is  an  infection  of  the  peri- 
toneum by  pathogenic  organisms.  It  is  always  a  secondary  disease, 
and  its  bacteriologic  factor  is  that  of  the  primary  lesion.  Thus,  perit- 
onitis may  follow  umbilical  infection  in  the  newly  born,  usually  due 
to  the  streptococcus  or  to  the  staphylococcus  aureus.  It  may  be  one 
of  the  lesions  resulting  from  a  general  blood  infection  with  the  pneumo- 
coccus,  the  influenza  bacillus,  or  streptococcus,  whether  the  point  of 
entrance  be  the  upper  respiratory  tract  or  a  surgical  wound.  Peritoni- 
tis may  follow  appendicitis,  enterocolitis,  or  intestinal  obstruction,  and 
is  then  most  often  due  to  Bacillus  coli  communis,  with  or  without  the 
streptococcus.  It  may  be  due  to  the  gonococcus,  as  the  result  of  the 
progressive  spread  of  vulvovaginitis,  endometritis,  and  salpingitis 
in  little  girls.  It  may  be  due  to  the  Bacillus  typhosus  in  the  course 
of  typhoid  fever.  Finally,  peritonitis  may  result  from  the  extension  of  a 
pleural  inflammation  by  means  of  the  lymphatics,  but  the  inflammation 
is  then  more  often  localized  about  the  spleen  or  liver  than  generalized. 

The  pneumococcus  probably  is  the  pathogenic  agent  in  more  than 
half  the  cases. 

PERITONITIS  AS  A  COMPLICATION 

The  disease  as  a  complication  is  not  infrequent.  I  have  seen 
cases  with  scarlet  fever,  with  enterocolitis,  with  appendicitis,  with 
endocarditis,  with  pneumonia  and  with  empyema. 

Pathology. — The  exact  character  of  the  inflammation  depends 
upon  the  infecting  organism.  The  process,  however,  uniformly  in- 
volves congestion,  exudation  of  serum  and  lymph,  and  the  formation 
of  adhesions.  Depending  on  the  source  and  degree  of  infection, 
peritonitis  may  be  localized,  spreading  or  general,  and  serous,  sero- 
purulent,  purulent,  or  fibrinous.  The  most  frequent  infecting  agents 
are  the  colon  and  the  typhoid  bacillus  and  the  streptococcus,  staphylo- 
coccus, pneumococcus,  and  gonococcus.  In  cases  of  streptococcus- 
peritonitis  the  fluid  is  thin  and  widely  diffused,  and  in  pneumococcus 
infections,  thick,  greenish-yellow,  purulent,  and  associated  with  fibrinous 
deposits  and  many  adhesions.  Gonococcal  peritonitis  is  seldom  diffuse. 
Pus  with  a  characteristic  fecal  odor  is  suggestive  of  appendical  or 
intestinal  perforation.  When  the  peritonitis  is  of  limited  extent,  the 
most  common  sites  for  the  localization  of  the  inflammation  are  the  iliac 
fossa,  pelvis,  and  subdiaphragmatic  regions.  Abscesses  occasionally 
perforate  spontaneously  at  the  umbilicus.  When  recovery  ensues, 
the  peritoneum  frequently  becomes  the  seat  of  permanent  adhesions 
which  may  or  may  not  occasion  symptoms. 

Symptoms. — There  are  but  three  diagnostic  symptoms  of  value: 
persistent  vomiting,   marked  tympanites,  and  obstinate   (and  often 


PERITONITIS    AS    A    COMPLICATION  257 

absolute)  constipation.     These  manifestations  comprise  a  symptom- 
complex  that  is  always  present  in  acute  peritonitis. 

The  temperature  is  usually  persistently  high — 103°  to  105°F. 
The  pulse  is  small,  soft,  and  quick,  and  the  child  appears  and  is 
very  ill.  The  respiration  is  short  and  rapid;  there  is  incomplete 
expansion.  There  are  no  evidences  of  pain  except  upon  manipulation. 
The  onset  of  all  symptoms  is  usually,  but  not  invariably,  abrupt.  It 
may  be  two  or  three  days  before  the  symptom-complex  as  described 
is  present. 

Duration  and  Prognosis. — Death  rarely  occurs  before  the  third 
day,  and  the  cases  that  pass  ten  days  are  rare.  I  have  never  known 
a  case  to  recover.  My  cases  have  all  been  in  children  under  two 
years  of  age,  with  two  exceptions.  One  was  a  child  of  three  with  a 
streptococcus  infection  occurring  with  endocarditis.  The  other  pa- 
tient, a  strong,  vigorous  girl,  three  years  of  age,  developed  a  moderately 
severe  enterocolitis.  Response  to  treatment  was  fairlj'  prompt,  and  in 
ten  days  the  child  was  convalescent.  Suddenly  she  developed  marked 
distention  of  the  abdomen,  persistent  vomiting,  and  obstinate  con- 
stipation. These  symptoms,  with  gradually  increasing  prostration, 
continued  for  three  days,  when  the  child  died.  The  autopsy  showed 
an  acute  general  streptococcic  peritonitis.  Streptococcus  was  found 
in  the  enlarged  mesenteric  glands,  proving  that  the  intestinal  tract 
was  the  source  of  the  infection.  The  prognosis  in  older  children  after 
the  fifth  year  is  said  to  be  more  favorable. 

Differential  Diagnosis. — The  only  condition  which  the  foregoing 
may  simulate  in  infants  and  runabouts  is  intestinal  obstruction, 
particularly  that  due  to  intussusception.  Intussusception  in  a  large 
majority  of  the  cases  occurs  in  infants  under  a  year  of  age.  Further,  in 
intussusception  there  is  no  associated  illness,  and  fever,  if  present,  is 
insignificant;  while  the  stools  almost  always  contain  blood-stained 
mucus  or  clear  white  mucus.  I  am  conviced  that  every  case  of  acute 
peritonitis  in  a  young  subject  should  have  the  benefit  of  an  exploratory 
incision.  There  is  always  a  possibility  in  obscure  cases  (and  most  cases 
are  obscure)  that  the  trouble  is  of  appendicular  origin  or  that  there  raaj^ 
be  some  other  localized  process  which  drainage  might  relieve.  Acute 
general  peritonitis  is  a  very  fatal  disease,  and  the  outlook  cannot  be 
made  worse  by  incision  and  drainage. 

Treatment. — Obviously,  it  would  be  unsatisfactory  to  the  reader 
to  have  the  treatment  of  a  disease  outlined  by  one  who  has  never  seen 
a  recovery  from  the  disease  in  question.  My  practice  is  to  call  a 
surgeon,  who  usually  refuses  to  operate.  An  exploratory  incision 
does  not  remove  any  of  the  chances  of  recovery,  and  there  is  always 
the  hope  that  drainage  may  be  of  value. 
17 


VI.  THE  RECTUM  AND  ANUS 


THE  RECTUM  IN  CHILDREN 


In  the  child,  the  division  between  the  pelvis  and  abdominal  cavities 
is  less  marked  than  in  the  adult,  and  the  rectum  is  less  distinctly  a 
pelvic  organ.  The  infantile  pelvis,  moreover,  is  peculiarly  narrow, 
so  that  the  course  of  the  terminal  portion  of  the  intestine  is  nearly 
perpendicular.  This  pecuHarity,  combined  with  the  greater  mobility 
of  the  child 's  rectum,  renders  digital  examination  per  rectum  of  great 
value  in  palpating  diseased  organs  within  the  abdomen.  The  same 
anatomic  conditions,  associated  with  weakness  of  the  levatores  ani, 
are  influential  in  the  causation  of  prolapsus  recti  in  children. 


PROLAPSE  OF  THE  ANUS  AND  RECTUM 

In  anal  prolapse  there  is  an  eversion  of  the  mucous  membrane, 
a  condition  often  presented  in  constipation  and  sometimes  seen  in 

diarrheal  conditions  of  the  dysenteric 
type,  in  which  there  is  a  tendency  to 
considerable  tenesmus  and  straining. 
If  the  case  is  neglected,  the  prolapse 
occurring  repeatedly  for  many  days 
in  succession  in  cases  of  constipation, 
or  several  times  a  day  in  the  acute 
diarrheal  cases,  the  sphincter  gradu- 
ally becomes  weakened,  the  prolapse 
more  pronounced,  and  soon  a  con- 
siderable portion  of  the  involuted 
rectum  appears  with  each  defecation. 
(See  Fig.  24.)  Such  children  usually 
show  evidence  of  illness  apart  from 
the  local  condition  and  the  constipa- 
tion. They  are  usually  underfed  and 
Many  are  rachitic,  or  show  the  ear-marks  of  a 


Fig.  24. — Prolapse  of  reotum  and 
anus. 


poorly  nourished, 
previous  rachitic  state. 

Treatment. — Cases  of  simple  eversion  are  usually  relieved  by  con- 
trolling the  diarrhea;  or,  when  due  to  constipation,  by  supporting  the 
perineum  during  defecation.  This  support  is  best  furnished  by  wrap- 
ping a  considerable  quantity  of  absorbent  cotton  around  the  index- 
finger,  which  rests  against  and  supports  the  perineum.  The  child 
should  lie  on  the  back  during  defecation.  The  troublesome  cases  are 
those  due  to  constipation  in  "runabout"  children,  in  whom  the  pro- 
lapse has  been  repeated  every  day  for  several  months.  In  such  cases 
a  wide  adhesive  strip  placed  across  the  buttocks,  high  enough  to  permit 

258 


PROLAPSE    OF   THE    ANUS   AND   RECTUM 


259 


of  bowel  evacuation,  will  often  prevent  the  prolapse.  The  case  rep- 
resented in  Fig.  25  was  brought  to  the  New  York  Polyclinic  in  the 
condition  shown  in  the  cut,  and  was  transferred  to  the  service  of  Dr. 
Wm.  Seaman  Bainbridge.  The  gut  was  practically  black,  and  its 
condition  raised  the  question  whether  there  was  not  sufficient  strangu- 


Fig.  25. — Involution  of  the  rectum,  sigmoid,  and  a  portion  of  the  descending  colon. 


lation  even  if  reduced,  to'  cause  death.  Hot  applications  were  placed 
upon  the  gut,  and  it  was  gradually  reduced,  but  prolapse  immediately 
followed.  In  order  to  keep  the  gut  in  position  a  long  rubber  tube  of 
large  caliber  was  inserted  into  the  rectum  and  passed  into  the  gut  as 
high  as  possible.     The  rectum  was  then  sewed  tightly  around  the  tube, 


260  THE    PRACTICE    OF    PEDIATRICS 

anchoring  the  rectal  outlet  to  the  tube  by  a  double  purse-string  suture 
of  strong  silk.  The  bowels  moved  through  the  tube,  and  for  days  there 
was  great  improvement.  The  use  of  the  long  tube  held  up  the  gut. 
Later  the  child  died  of  pneumonia,  but  it  was  possible  to  remove  the 
tube  and  then  prolapse  did  not  take  place. 

INFLAMMATION  OF  THE  ANUS 

An  acute  painful  inflammation  of  the  anus  and  of  the  skin  surround- 
ing it  is  frequently  seen  in  children  after  a  diarrhea  of  some  days'  dura- 
tion. It  is  also  seen  in  weakly,  delicate  children  without  any  marked 
intestinal  disturbance.  The  inflammation  produces  considerable  dis- 
tress during  the  passage  of  a  stool,  and  is  conducive  to  constipation, 
because  the  child  soon  dreads  to  have  a  bowel  movement  and  tries  to 
avoid  it. 

Treatment. — The  child's  nutrition  and  management  in  general 
must  be  first  carefully  looked  after,  as  elsewhere  suggested  (p.  105). 
For  the  local  trouble,  the  free  use  of  warm  water  after  each  defecation 
is  necessary.  This  is  to  be  followed  by  a  generous  application  of  an 
ointment  made  as  follows. 

I^    Ichthyolis 3  j 

Unguenti  aquae  rosse 5  j 

Instructions  are  given  that  the  parts  are  to  be  kept  covered  with  the 
ointment,  applied  on  a  piece  of  old  linen,  which  should  be  changed 
every  three  hours.  This  treatment  is  usually  followed  by  prompt 
relief. 

FISSURE  OF  THE  ANUS 

Anal  fissure  is  a  condition  that  usually  occurs  in  quite  young  chil- 
dren. I  have  seen  comparatively  few  cases  in  those  over  two  years  of 
age.  Rough  manipulation  may  be  a  cause,  as  in  the  case  of  unskilled 
use  of  the  syringe  or  rectal  tube.  With  very  few  exceptions,  however, 
the  fissure  is  due  to  the  stretching  of  the  parts  by  the  passage  of  large 
fecal  masses,  which  cause  minute  lacerations  of  the  mucous  membrane 
within  the  anal  ring.  Under  a  good  light,  gentle  separation  of  the 
buttocks  will  usually  bring  the  laceration  into  view. 

Symptoms. — There  are  few  more  painful  affections.  The  vigorous 
crying  preceding  and  during  the  defecations  aids  the  mother  in  locat- 
ing the  source  of  the  child's  trouble.  Occasionally  the  fecal  mass  will 
be  streaked  with  blood.  The  constipation  which  causes  the  trouble 
is  aggravated  by  the  painful  nature  of  the  condition,  as  the  child  soon 
learns  to  dread  an  evacuation,  and  postpones  the  act  until  medication 
or  some  manipulative  means  is  employed  to  induce  a  movement. 

Illustrative  Case. — A  little  girl,  twenty  months  old,  was  brought  to  me  because 
she  cried  and  objected  to  being  placed  in  position  for  a  bowel  evacuation,  and  cried 
even  more  during  the  evacuation.  On  the  day  preceding  the  visit  to  my  office  the 
mother  feared  the  child  would  have  a  convulsion,  so  great  was  her  distress.  Ex- 
amination of  the  rectum  showed  two  rather  small  fissures  extending  through  the 
anal  mucous  membrane. 


PROCTITIS  261 

Treatment. — Diet. — For  a  prompt  repair  of  the  fissures  it  is 
necessary  to  render  the  stools  soft.  This,  in  the  bottle-fed,  is  often 
easily  accomplished  by  the  addition  to  each  feeding,  of  one  or  two 
teaspoonfuls  of  one  of  the  malted  foods,  such  as  Mellin  's  food  or  malted 
milk.  In  other  instances  one  feeding  of  malted  milk  each  day  may 
be  substituted  for  one  of  the  regular  feedings,  in  the  strength  of  4  to  6 
teaspoonfuls  in  8  ounces  of  water. 

Drugs. — If  drugs  are  necessary  or  are  preferred,  the  addition  of  2 
teaspoonfuls  daily  of  the  milk  of  magnesia  to  the  milk  food  will  prove 
of  value.  A  teaspoonful  of  sweet  oil  after  two  or  more  feedings  will 
likewise  usually  have  the  desired  softening  effect  upon  the  stool. 

Local  Measures. — Proper  regulation  of  the  bowel  function,  while 
absolutely  necessary  for  a  cure  of  the  laceration,  is  not  of  itself  sufficient 
to  effect  permanent  relief.  The  parts  must  be  thoroughly  washed 
with  warm  water  and  Castile  soap  after  each  defecation.  After  the 
washings,  and  at  three-hour  intervals  during  the  day,  25  per  cent,  of 
ichthyol-ammonium-sulphate  in  zinc  ointment  should  be  applied  with 
a  clean  index-finger,  which  is  introduced  well  up  into  the  anal  aperture. 
If  the  fissure  is  deep,  the  treatment  should  be  begun  by  cocainizing 
the  parts  with  a  3  per  cent,  solution  of  cocain.  The  fissure  may  then 
be  cauterized  with  a  50  per  cent,  solution  of  nitrate  of  silver,  applied 
on  a  cotton-tipped  probe.  Twelve  hours  later  the  ichthyol  ointment 
may  be  used  as  in  the  milder  cases.  I  have  yet  to  see  a  case  which  does 
not  respond  to  the  above  treatment  if  it  is  faithfully  carried  out. 

PROCTITIS 

Inflammations  of  the  rectum  are  of  three  different  forms — catarrhal, 
croupous  or  membranous,  and  ulcerative. 

Catarrhal  proctitis  is  usually  associated  with  a  colitis  higher  in  the 
bowel.  When  confined  to  the  rectum,  the  process  may  be  due  to  the 
careless  use  of  irrigations  or  irritating  suppositories,  or  the  activity  of 
thread- worms. 

The  mucous  membrane  is  red  and  swollen,  and  exudes  not  only 
mucus,  but  a  small  amount  of  blood.  In  gonorrheal  proctitis,  which 
occasionally  complicates  a  vulvovaginal  infection  by  the  same  organ- 
ism, the  discharge  from  the  inflamed  parts  is  characteristically 
purulent. 

Membranous  proctitis  may  result  from  diphtheria  of  the  genitals 
or  from  a  local  streptococcus  infection.  The  morbid  lesions  closely 
resemble  those  of  membranous  colitis,  and  are  not  essentially  different 
from  those  which  occur  in  membranous  inflammations  of  the  throat. 
The  grayish,  organized  exudate  may  be  visible  on  the  mucosa  of  the 
prolapsed  bowel,  or  appear  in  fragments  in  the  stools. 

Ulcerative  proctitis  is  usually  secondary  to  a  severe  catarrhal  proc- 
titis, in  which  case  the  lesions  tend  to  remain  superficial.  Follicular 
ulcers  of  greater  depth  may  occur  in  connection  with  follicular  colitis. 
Syphilitic  and  tuberculous  ulcerations  of  the  rectum  are  rare.     Holt 


262  THE    PKACTICE    OF    PEDIATRICS 

reports  one  case  of  the  tuberculous  type,  and  records  Steffen  's  obser- 
vations of  three  others. 

Symptoms. — In  all  forms  of  proctitis  the  movements  of  the  bowels 
are  frequent,  and  associated  with  tenesmus  and  the  discharge  of 
mucus  and  small  amounts  of  blood.  Prolapsus  recti  is  not  uncommon, 
and  after  reduction,  shows  a  strong  tendency  to  recur  so  long  as  the 
severe  peristaltic  activity  of  the  bowel  persists.  The  character  of  the 
discharge  is  of  value  in  differentiating  the  existing  type  of  inflammation. 

Treatment. — In  mild  cases  of  the  catarrhal  form  injections  of  warm 
starch  solution,  alkaline  liquid  antiseptics,  or  sweet  oil  will  effect  a 
cure,  provided  the  primary  cause  of  the  irritation  has  been  removed. 
When  the  process  is  diphtheric,  antitoxin  should  be  promptly  adminis- 
tered, as  in  cases  of  laryngeal  diphtheria. 

Ulcerative  proctitis  requires  especial  care  involving  the  use  of 
cleansing  irrigations  and  suppositories  of  tannigen,  belladonna,  opium, 
or  cocain,  combined  with  local  application,  at  intervals,  of  a  solution 
of  silver  nitrate  of  0.2  to  0.5  per  cent,  strength.  For  the  gonorrheal 
cases  Koplik  advises  rectal  injections  of  2  per  cent,  protargol  solution, 
at  a  temperature  of  105°  to  108°F.,  twice  daily. 

ISCHIORECTAL  ABSCESS 

An  abscess  of  this  nature  is  the  result  of  a  preceding  adenitis  of  the 
lymph-glands  in  the  neighborhood  of  the  rectum. 

Symptoms. — The  first  sign  will  be  that  of  pain  on  defecation  or 
upon  manipulation.  Upon  examination  an  oval,  indurated  mass  will 
be  found  under  the  skin,  usually  not  deeply  placed.  Much  pain  is  evi- 
denced during  the  examination.  In  most  instances  there  will  be  red- 
ness of  the  skin  over  the  involved  gland.  Rarely  can  fluctuation  be 
made  out  by  palpation.  Suppuration,  however,  follows  the  primary 
infection  very  rapidly,  and  a  distinct  area  of  reddened  and  inflamed 
skin  indicates  the  presence  of  pus  beneath.  Children's  hospitals, 
children's  asylums,  and  dispensary  services  supply  the  majority  of  these 
patients.     Occasionally  a  case  is  seen  in  private  work. 

Treatment.— All  that  is  required  is  a  free  incision,  daily  washing- 
out  of  the  abscess  cavity  with  a  3  per  cent,  solution  of  hydrogen  peroxid, 
and  packing  with  sterilized  gauze  moistened  with  a  saturated  solution 
of  boric  acid.  A  layer  of  gauze,  covered  with  oiled  silk,  should  cover 
the  dressing,  to  protect  the  wound  from  further  infection  by  the  fecal 
discharges.  In  case  the  granulations  are  sluggish,  as  they  may  be  in 
marasmic  infants,  the  gauze  used  for  the  packing  may  be  saturated  with 
the  balsam  of  Peru. 


VIL  THE  SPLEEN  AND  THE  LIVER 
The  Spleen 

In  children  the  spleen  is  very  rarely  the  seat  of  primary  disease. 
Sarcoma,  carcinoma,  abscess,  and  cysts,  with  primary  involvement  of 
the  spleen,  have  been  reported.  This  organ,  however,  frequently  shows 
secondary  involvement  and  furnishes  an  important  diagnostic  sign  in 
a  large  number  of  diseases.  Thus  the  spleen  is  enlarged  in  syphilis, 
in  rachitis,  typhoid  fever,  in  persistent  intestinal  infections,  in  malaria, 
in  cirrhosis  of  the  liver,  in  right  heart  failure,  and  in  practically  all  the 
blood  diseases  of  early  life. 

Usually  the  organ  shows  a  simple  enlargement,  which  subsides 
when  the  disease  causing  the  condition  is  removed.  As  the  result  of 
repeated  or  persistent  enlargement  for  a  considerable  time,  as  in  malaria 
and  some  of  the  blood  disorders,  it  undergoes  hyperplasia  and  per- 
manent enlargement. 

SPLENOMEGALY 

Primary  splenomegaly  of  the  Gaucher  type  is  of  unknown  origin. 
The  probable  cause  is  a  chronic  toxic  agent,  -to  which  a  family  predis- 
position exists. 

Splenomegaly  in  infantile  splenic  anemia  has  been  found  to  be 
associated  with  a  parasite,  Leishmania  infantum,  similar  to  the  Liesh- 
man-Donovan  parasite,  which  is  the  cause  of  kala-azar.  The  parasite 
was  discovered  in  the  infantile  cases  by  Pianese  and  Nicolle. 

Splenomegaly  occurs  in  cases  of  septicemia,  malaria,  tuberculosis, 
syphilis,  rachitis,  leukemia,  Hodgkin's  disease,  and  anemia  infantum 
pseudoleuksemia.  In  pernicious  anemia  the  spleen  is  rarely  very 
large. 

Neoplasms  (sarcoma,  angioma,  fibroma,  cysts)  of  the  spleen  are 
very  rare. 

Obstruction  of  the  portal  circulation  may  cause  splenomegaly,  as 
in  cirrhosis  of  the  liver,  heart  disease,  or  pressure  from  a  new-growth. 

The  Liver 

The  liver  in  infants  and  children  is  very  rarely  the  seat  of  primary 
disease.  In  the  mortality  of  childhood,  as  an  immediate  cause  of  fatal 
diseases  the  liver  plays  a  very  unimportant  role. 

Derangement  of  function,  on  the  other  hand  is  unquestionably 
at  the  bottom  of  many  disorders  not  at  all  understood  at  the  present 
time. 

263 


264  THE    PRACTICE    OF    PEDIATRICS 

Fatty  change  in  the  liver  in  early  life  is  often  found  at  autopsy. 
It  is  found  in  greater  or  less  degree  in  practically  all  infants  and  young 
children  who  die  from  prolonged  and  exhausting  diseases. 

Presumably  the  infiltration  is  of  a  temporary  nature,  and,  so  far 
as  is  known,  has  no  symptomatology  of  its  own.  In  many  cases  that 
recover  the  liver  must  have  undergone  fatty  changes.  It  is  rare  not 
to  find  more  or  less  fatty  changes  at  a  postmortem  examination  of  a 
child  under  one  "year  of  age.  In  some  cases  the  involvement  is  so  ex- 
tensive that  the  entire  organ  is  firm,  smooth,  and  of  a  yellowish  color. 
In  other  cases  there  are  only  localized  evidences  of  the  fatty  process. 
Usually  the  organ  is  not  enlarged.  The  condition  is  not  to  be  diagnosed 
during  life.  If  there  is  a  derangement  of  function,  this  is  not  of  such  a 
nature  as  to  make  the  actual  hepatic  conditions  manifest. 

Acute  Yellow  Atrophy. — Fatal  cases  of  this  disease  in  children  are 
reported  at  rare  intervals. 

Abscess  of  the  liver  in  the  newly  born  is  the  result  of  an  infection 
usually  acquired  from  the  umbilical  veins.  Several  cases  have  been 
reported  in  literature,  in  which  the  abscess  was  caused  by  the  migration 
of  round- worms  into  the  hepatic  duct  in  older  children. 

Abscess  of  the  liver  may  result  in  any  pyemic  condition.  Its  rare 
occurrence  demonstrates  the  hepatic  powers  of  resistance  against 
microbic  invasion. 

The  Amoeba  coli  has  been  the  cause  in  a  considerable  number 
of  cases. 

Symptoms. — Enlargement  of  the  organ,  associated  with  the  pres- 
ence of  marked  tenderness,  is  usual.  Pain  is  a  very  constant  symptom, 
and  may  be  referred  to  different  points  in  the  abdomen.  Not  infre- 
quently it  is  felt  at  the  umbilicus,  or  it  may  be  localized  between  the 
right  scapula  and  spine.  Among  the  most  prominent  active  manifes- 
tations, are  repeated  chills,  a  widely  ranging  septic  temperature,  and 
vomiting.     Occasionally  there  is  diarrhea. 

Exploration  should  be  performed,  and  if  pus  is  located,  aspiration 
and  drainage  should  follow.  Abscesses  not  operated  upon  are  apt  to 
perforate  into  the  peritoneal  or  pleural  cavity.  Cases  of  perforation 
into  the  intestine  have  been  followed  by  recovery. 

Cirrhosis  of  the  Liver. — Cirrhosis  of  the  liver  belongs  to  the  curiosi- 
ties of  pediatric  practice.  All  the  cases  reported  represent  the  obser- 
vations of  as  many  men. 

In  the  reported  cases  in  which  there  has  been  a  supposed  etiologic 
factor,  syphilis,  alcohol,  and  the  infectious  diseases  have  been  looked 
upon  as  the  agencies  causing  the  disease. 

Toxic  substances  of  widely  different  character  are  apparently  capa- 
\>\e  of  causing  cirrhosis  of  the  liver  in  the  young. 

Symptoms. — At  first  there  is  enlargement  of  the  liver  and  the  spleen. 
Persistent  but  not  severe  icterus  and  ascites  supervene.  The  patient 
shows  early  evidences  of  malnutrition,  and  a  cachexia  that  is  strongly 
suggestive  of  the  underlying  condition.  As  the  case  progresses  the 
liver  becomes  very  much  reduced  in  size,  diarrhea  becomes  fairly  con- 


ICTERUS    (obstructive   JAUNDICE;   CATARRHAL  JAUNDICE)       265 

stant,  vomiting  frequent,  and  dilatation  of  the  superficial  abdominal 
veins  occurs.  Bronchopneumonia  is  the  usual  terminal  complication. 
Treatment. — The  management  is  entirely  symptomatic.  Tapping 
may  temporarily  relieve  the  embarrassed  respiration  and  the  general 
discomfort  occasioned  by  the  large  amount  of  fluid  in  the  abdominal 
cavity. 

ICTERUS  (OBSTRUCTIVE  JAUNDICE;  CATARRHAL  JAUNDICE) 

Jaundice  of  this  type  in  children  is  usually  associated  with  duoden- 
itis, and  is  caused  by  a  swelling  of  the  lymphoid  bodies  in  the  mucous 
membrane  of  the  common  bile-duct  at  its  terminal  opening  into  the 
intestine.  The  jaundice  is  due  probably  to  the  same  form  of  infection 
that  caused  the  duodenitis.  Cases  often  occur  in  groups  of  two  or  three 
in  the  same  family.  In  November,  1911,  three  children  and  two  adults 
— the  mother  and  nurse — had  pronounced  jaundice  with  the  usual 
manifestations.  Six  weeks  before,  all  these  people  had  suffered  from 
malaria.  I  have  seen  but  one  case  in  which  jaundice  was  due  to 
cholelithiasis.  This  patient,  a  girl  six  years  of  age,  had  distinct  at- 
tacks of  biliary  colic,  accompanied  by  passage  of  gall-stones  and  fol- 
lowed by  intense  jaundice.  She  was  eventually  operated  upon  and 
many  stones  were  removed  from  the  gall-bladder. 

Symptoms. — The  onset  of  my  cases  has  almost  never  been  marked 
by  high  temperature  or  evidence  of  severe  gastric  disturbance.  Usually 
the  first  signs  have  been  loss  of  appetite,  coated  tongue,  rise  of  a  de- 
gree or  two  in  temperature,  and  listlessness.  The  yellow  discoloration 
of  the  conjunctiva  and  skin  soon  appears,  and  this,  with  the  high- 
colored  urine  and  slightly  colored  or  grayish  stools,  makes  the  case 
complete. 

The  liver  is  usually  enlarged  an  inch  or  two  below  the  ribs,  and 
often  is  slightly  tender.     The  spleen  is  also  slightly  enlarged. 

I  have  never  known  a  fatal  case,  although  such  have  been  reported. 

Vomiting. — In  my  most  severe  case  the  vomiting  continued  for 
five  days,  neither  food  nor  water  being  retained.  Vomiting  is  present 
in  most  cases.  The  child  vomits  two  to  three  times,  or  at  intervals 
for  a  day  or  two. 

Treatment. — Diet. — The  reason  why  gastric  disorder  is  considered 
so  prominent  a  symptom  by  many  writers  is  possibly  because  of  the 
gastric  disturbance  produced  by  the  treatment.  We  are  advised 
to  place  the  patient  on  a  milk  diet  and  give  calomel.  I  know  of  no 
treatment  better  calculated  to  produce  vomiting  and  increase  both 
the  intestinal  infection  and  the  jaundice.  The  treatment  which  I 
have  found  most  satisfactory  is  the  use  of  very  little  food  for  twenty- 
four  hours.  Water  is  given  as  a  drink,  and  later,  well-salted  chicken 
or  mutton  broth  may  be  given  with  toast,  if  the  child  asks  for  food. 
He  should  not  be  urged  to  eat.  The  following  day  broths,  gruels,  and 
orange-juice,  with  stewed  fruits  or  lemonade,  are  given  if  wanted. 

Drugs. — The  only  medication  used  consists  of  rhubarb  and  soda. 


266  THE    PRACTICE    OF   PEDIATRICS 

To  a  child  five  years  of  age  I  give  4  grains  of  pulverized  rhubarb  and  8 
grains  of  bicarbonate  of  soda  from  two  to  three  times  daily,  giving  at 
the  same  time  considerable  water.  For  a  day  or  two  sufficient  medi- 
cine should  be  given  to  produce  a  free  laxative  effect,  but  not  nec- 
essarily enough  to  purge  the  patient.  Usuallj^  on  the  third  day  I 
begin  with  tincture  of  nux  vomica  and  dilute  hydrochloric  acid — from 
2  to  4  drops  of  each,  well  diluted.  When  the  stools  are  again  normal, 
the  usual  diet  may  be  resumed,  milk  not  being  used  for  a  week  after- 
ward.    Rhubarb  and  soda  are  best  given  as  follows: 

I^     Pulveris  rhei gr.  xlviij 

Sodii  bicarbonatis gr.  xcvj 

Syrupi  rhei  aromatici §| 

Aquse q.  s.  ad  gij 

M.  Sig. — Shake  well.     One  teaspoonful  two  or  three  times  daily  after 
meals. 


VHL  DISEASES  OF  THE  RESPIRATORY  TRACT 

The  Nose  and  Throat 
acute  rhinitis  (coryza;  snuffles;  cold  in  the  head) 

Acute  rhinitis  is  a  very  common  ailment  throughout  childhood. 
Newly  born  babes,  "  runabouts,"  and  school-children  alike  are  suffer- 
ers. The  so-called  cold  in  the  head  is  unquestionably  an  infection  and 
may  be  transmitted  from  the  diseased  to  the  well.  That  a  species 
of  microorganism  has  not  been  demonstrated  in  no  way  invalidates 
this  statement.  I  have  time  and  again  seen  an  acute  rhinitis  develop 
in  one  member  of  a  family  and  pass  through  the  entire  household 
of  perhaps  six  or  eight  persons,  adults  and  children.  Infants  and 
young  children  should  not  come  in  contact  with  other  persons  suffering 
from  acute  rhinitis. 

Symptoms. — The  onset  is  usually  sudden,  and  characterized  by 
sneezing  and  difficulty  in  breathing  through  the  nose.  This  may 
continue  for  a  few  hours  or,  in  some  cases,  for  a  day  or  two.  At  the 
expiration  of  this  time  a  mucous,  watery  nasal  discharge  appears. 
Infants  are  the  greatest  sufferers,  owing  to  the  fact  that  breathing, 
which  has  to  be  carried  on  largely  through  the  mouth,  is  rendered  dif- 
ficult, and  nursing,  in  consequence,  is  frequently  interrupted.  A  de- 
gree or  two  of  fever  may  exist  at  the  commencement  of  the  attack,  but 
any  elevation  of  temperature,  as  a  rule,  lasts  only  a  few  hours.  Neg- 
lected cases  sometimes  become  infected  with  pyogenic  bacteria  (stap- 
phylococcus,  pneumococcus,  and  streptococcus),  in  which  event  a 
troublesome  purulent  rhinitis  results.  In  the  majority  of  the  neglected 
cases,  and  in  some  of  those  that  are  well  treated,  the  rhinitis  is  the 
beginning  of  an  infection  of  the  mucous  membrane,  which  involves 
successively  the  fauces,  tonsils,  larynx,  and  bronchi.  Repeated  attacks 
doubtless  contribute  to  the  production  of  adenoid  growths  in  the  naso- 
pharjmgeal  vault.  Otitis  media  is  not  an  infrequent  outcome,  par- 
ticularly if  the  child  has  adenoids. 

Differential  Diagnosis. — ^Acute  simple  rhinitis  is  to  be  differen- 
tiated from  specific  rhinitis,  which  is  one  of  the  first  manifestations 
of  congenital  syphilis.  When  due  to  syphilitic  infection,  the  condition 
is  uninfluenced  by  the  usual  treatment.  There  is  no  tendency  for  it 
to  descend  and  involve  the  mucous  membrane  of  the  bronchi.  The 
hoarseness  of  congenital  syphilis  is  persistent  and  of  gradual  develop- 
ment. Furthermore,  if  the  rhinitis  is  due  to  syphilis,  other  diagnos- 
tic signs  are  present  or  will  soon  appear. 

Measles  almost  invariably  begins  as  an  acute  rhinitis.  The  accom- 
panying conjunctivitis,  the  hard,  dry,  hacking  cough,  and  the  character- 
istic rash  soon  make  the  diagnosis  possible.  In  nasal  diphtheria  there  is 
invariably  a  discharge  from  the  nose  which  may  be  differentiated  from 

267 


268  THE    PRACTICE    OF    PEDIATRICS 

that  of  simple  rhinitis  by  the  fact  that  the  discharge  in  diphtheria  is 
excoriating  in  character  and  is  often  tinged  with  blood.  A  diphtheric 
discharge  may  be  hmited  entirely  to  one  nostril  or  may  be  greater 
from  one  nostril  than  the  other;  while  in  acute  simple  rhinitis  the 
amount  of  the  discharge  is  usually  the  same  from  both  sides.  In- 
fluenza begins  with  sneezing  and  nasal  discharge,  serous  in  character. 
In  influenza,  however,  there  will  be  associated  cough,  fever,  and  more 
or  less  prostration. 

Duration. — The  tendency  of  acute  simple  rhinitis  in  a  strong 
child  is  toward  recovery  in  five  or  six  days.  When  the  surroundings 
are  unfavorable,  or  the  child  is  delicate  or  rachitic,  active  treatment 
will  be  required  to  bring  about  a  prompt  recovery. 

Complications. — Simple  rhinitis  is  very  often  the  beginning  of  an 
infection  which  may  reach  the  middle  ear  and  produce  purulent  otitis 
or  mastoid  disease.  Cervical  adenitis  is  not  an  infrequent  outcome. 
Retropharyngeal  adenitis  and  retropharyngeal  abscess,  acute  laryngi- 
tis, bronchitis,  and  bronchopneumonia,  may  all  result  from  acute 
rhinitis.  Early  treatment  and  care  of  the  primary  condition  are,  there- 
fore, exceedingly  important. 

Treatment.^ — -The  first  step  is  the  administration  of  two  teaspoon- 
fuls  of  castor  oil.  During  the  initial  stage  of  engorgement  much  may 
be  accomplished  for  the  very  young  by  local  medicaments.  One  of  the 
best  is  menthol,  3^^  grain,  dissolved  in  1  ounce  of  liquid  albolene.  Of 
this  solution  3  drops  should  be  instilled  into  each  nostril  every  hour 
by  means  of  a  medicine-dropper.  This  treatment  alone  will  relieve 
the  patient  of  distressing  obstruction  and  facilitate  freer  breathing. 
Older  children  may  use  a  spray  containing  1  grain  of  menthol  to  1 
ounce  of  hquid  albolene  at  intervals  of  two  or  three  hours. 

In  case  menthol  and  albolene  are  not  at  hand,  melted  white  vaselin 
may  be  similarly  employed. 

For  internal  use  the  following  medication  has  served  me  well: 

At  least  six  doses  should  be  given  in  the  twenty-four  hours. 
For  a  child  three  months  of  age: 

I^    Tincturae  belladonnae gtt.  vij 

Pulveris  camphorae gr.  iv 

Sacchari  lactis,  q.  s. 

M.  div.  et  ft.  tabellge  no.  xxx. 

Sig. — One  tablet  every  two  hours. 

Six  months  of  age: 

I^     Tincturse  belladonnae gtt.  x 

Pulveris  camphorse gr.  v 

Pulveris  ipecacuanhse  et  opii gr.  iv 

Sacchari  lactis,  q.  s. 

M.  div.  et  ft.  tabellaj  no.  xxx. 

Sig. — One  every  two  hours  in  water. 

From  one  to  two  years  of  age : 

I^     Tincturse  belladonna; gtt.  xv 

Pulveris  camphorse gr.  vj 

Pulveris  ipecacuanha;  et  opii gr.  x 

M.  div.  et  ft.  tabella;  no.  xxx. 

Sig. — One  every  two  hours. 


CHRONIC    RHINITIS    (nASAL    CATARRH)  269 

Prom  two  to  four  years  of  age: 

I^     Tincturse  belladonnae gtt.  xv 

Pulveris  camphorae gr-  vj 

Pulveris  ipecacuanhae  et  opii gr.  xv 

Sacchari  lactis,  q.  s. 

M.  div.  et  ft.  tabellae  no.  xxx. 

Sig. — One  every  two  hours. 

If  for  any  reason  the  tablets  cannot  be  prepared,  powders  will 
answer  the  purpose  equally  well. 

The  above  prescriptions  are  indicated  for  the  second  or  catarrhal 
stage,  in  which  we  usually  find  the  patient  on  beginning  treatment. 
We  must  guard  against  the  constipating  effects  of  the  camphor  and 
the. Dover's  powder. 

In  the  treatment  of  nasal  disorders  the  forcible  use  of  the  syringe, 
or  any  form  of  nasal  irrigation  which  requires  force,  should  be  con- 
demned. Infection  is  easily  carried  into  the  Eustachian  tubes,  and  may 
give  rise  to  very  grave  complications.  A  suppurative  otitis  is  thus 
very  easily  produced. 

An  enema  of  warm  sweet  oil  or  soapsuds  should  be  administered 
if  the  bowels  do  not  m.ove  once  in  twenty-four  hours.  In  treating  chil- 
dren of  a  markedly  constipated  habit  the  Dover's  powder  may  be 
omitted.  Internal  medication,  if  begun  early  and  properly  carried  out, 
will  not  be  needed  for  more  than  two  or  three  days.  During  an 
attack  of  acute  rhinitis  the  child  should  not  be  unnecessarily  exposed 
to  cold,  owing  to  the  strong  tendency  of  the  inflammation  to  descend 
and  involve  the  deeper  portion  of  the  respiratory  tract. 

CHRONIC  RHINITIS  (NASAL  CATARRH) 

Nasal  discharge,  more  or  less  constant,  is  present  in  not  a  few  in- 
dividuals throughout  childhood.  In  the  majority  of  those  affected 
this  discharge  begins  with  the  onset  of  cold  weather  and  lasts  until 
spring.  The  secretion  may  be  composed  of  thin,  watery  mucus,  or  it 
may  be  mucopurulent  in  character. 

Etiology. — ^In  order  to  treat  this  condition  successfully  the  source 
of  the  discharge  must  be  discovered.  It  may  be  due  to  several  causes, 
which  are  here  given  in  the  order  of  their  frequency  • 

1 .  Adenoids  in  the  nasopharyngeal  vault. 

2.  Hypertrophy  of  the  turbinated  bones,  with  septal  deviations 
and  hypertrophy  of  the  mucous  membranes. 

3.  Infection  due  to  pyogenic  bacteria.  When  present,  this  may 
follow  acute  rhinitis,  but  is  more  often  the  sequel  of  one  of  the  infectious 
diseases.  The  discharge  may  be  distinctly  purulent  and  is  often  very 
profuse. 

4.  Infection  due  to  the  Klebs-Loffler  bacillus.  I  have  seen  a  great 
many  cases  of  this  type  in  children  under  eight  years  of  age,  in 
whom  a  serous  discharge  from  one  or  both  nostrils  has  persisted  for  a 
considerable  period  of  time — in  one  instance  for  an  entire  year.  Ex- 
amination of  the  discharge  showed  the  presence  of  the  Klebs-Loffler 


270  THE    PRACTICE    OF    PEDIATRICS 

bacillus.  Such  children  are  not  ill,  and  are  brought  to  a  physician 
solely  for  treatment  of  the  nasal  discharge.  The  cases  do  not  clear  up 
under  ordinary  methods  of  treatment,  but  promptly  respond  when 
from  1500  to  2000  units  of  diphtheria  antitoxin  is  given. 

5.  Hay-fever  is  characterized  by  a  periodic  discharge  which  may  be 
said  to  be  chronic  in  character,  persisting  over  several  weeks. 

6.  Malnutrition.  A  thin,  watery  discharge,  apparently  due  to 
relaxed  mucous  membranes,  occurs  in  weak  and  poorly  nourished 
children  with  no  other  abnormal  condition  to  explain  the  trouble  than 
the  general  weakness. 

7.  Disease  of  the  sinuses.  Sinus  infection  of  a  mild  type  may 
cause  persistent  rhinitis  without  other  symptoms,  and  these  cavities 
should  be  examined  in  obscure  cases. 

8.  Foreign  bodies.  A  foreign  body  in  either  nostril  will  produce 
a  persistent  discharge.  When  a  child  is  brought  to  me  with  a  history 
of  a  persistent  serous  or  purulent  discharge  from  one  nostril,  I  invariably 
examine  for  a  foreign  body,  and  repeatedly  have  found  this  discharge 
explained  by  the  presence  of  a  pea,  a  bean,  a  piece  of  coal,  or  a  button. 
At  the  out-patient  department  of  the  Babies'  Hospital  a  child  three 
years  of  age  was  brought  for  treatment  of  a  persistent  right-sided  nasal 
discharge  which  had  existed  for  seven  months.  Examination  showed 
a  foreign  body  well  up  in  the  nostril.  This  object  was  removed  with 
considerable  difficulty  and  proved  to  be  a  piece  of  cork. 

In  these  cases  of  chronic  rhinitis  the  possibility  of  adenoids  (see  p. 
293)  should  never  be  forgotten;  for  their  existence  cannot  be  excluded 
because  a  child  is  not  a  mouth-breather  and  does  not  snore.  A  child 
with  a  chronic  "cold  in  the  head"  almost  invariably  has  adenoid 
vegetations  in  the  nasopharyngeal  vault.  Examination  may  reveal 
that  the  nasopharyngeal  space  is  blocked  by  the  growth,  so  that  entrance 
with  the  finger  is  almost  impossible.  In  other  instances  only  a  small, 
pulpy  mass  will  be  found,  or  a  ridge  of  soft,  friable  growth  at  the  upper 
portion  of  the  vault,  not  large  enough  to  produce  signs  of  obstruction, 
but  actively  secreting  and  manifestly  the  source  of  the  discharge. 
Children  who  have  anterior  nasal  defects,  such  as  hypertrophies  of 
bone  or  thickening  of  the  membranes,  usually  have  adenoids  as  well. 
In  fact,  adenoids  play  no  small  part  in  most  of  the  catarrhal  affections 
of  the  upper  respiratory  tract  in  children,  and  an  examination  of  a 
child  with  a  nasal  discharge  or  a  cough  which  is  difficult  to  explain 
is  never  complete  without  an  exploration  of  the  nasopharyngeal  vault. 

Treatment. — The  treatment  consists  in  correcting  the  condition 
which  causes  the  discharge.  If  adenoids  are  present  in  a  sufficient 
amount  to  cause  trouble,  they  should  be  removed  (p.  298).  No  other 
treatment  is  of  any  avail.  For  deformities  and  hypertrophies  of  the 
anterior  nasal  structure  operative  measures  are  also  essential,  but 
should  be  carried  out  by  one  skilled  in  rhinoplastic  work.  Purulent 
rhinitis,  primary  or  following  the  infectious  diseases,  is  best  treated 
by  a  spray  composed  of  liquid  albolene,  1  ounce,  ichthyol  ammonium 
sulphate,  2  grains,  which  should  be  thoroughly  shaken  before  using. 


THKOAT    EXAMINATION  271 

This  spray  should  be  used  every  two  hours  while  the  child  is  awake. 
Once  or  twice  a  day  it  may  be  well,  if  the  secretion  is  profuse  and  puru- 
lent, to  instil  into  the  nostril  about  20  minims  of  a  1  : 6  aqueous  solution 
of  hydrogen  peroxid.  If  the  Klebs-Loffler  bacillus  is  present,  antitoxin 
alone  will  control  the  disease,  and  that  very  promptly. 

The  anemic  and  poorly  nourished  patients,  who  show  almost  no  ab- 
normaHty,  but  suffer  more  or  less  from  a  constant  serous  discharge, 
are  benefited  by  constitutional  measures  only — a  dry  climate,  plain, 
nourishing  food,  iron,  cod-liver  oil,  massage,  and  salt  baths.  Suitable 
management  is  referred  to  in  detail  under  The  Management  of  Delicate 
Children  (p.  122).  Applied  to  these  children,  local  treatment,  apart 
from  cleanliness,  is  a  loss  of  time  and  energy. 

NASAL  HEMORRHAGE 

Non-traumatic  nasal  hemorrhage  in  a  child  usually  occurs  from  one 
of  two  sources — adenoid  vegetations  in  the  nasopharyngeal  vault  or 
an  erosion  or  ulceration  of  the  mucous  membrane  covering  the  free 
vascular  area  of  the  anterior  portion  of  the  nasal  septum. 

Treatment. — When  the  hemorrhage  is  due  to  the  adenoid  growth, 
it  is  usually  readily  controlled  by  keeping  the  child  in  an  upright 
position,  or  by  the  application  of  cold  to  the  back  of  the  neck — pref- 
erably by  a  piece  of  ice  wrapped  in  a  table  napkin  or  by  an  ice-bag. 
When  the  hemorrhage  is  due  to  an  erosion  of  the  septum  and  pressure  of 
the  finger  on  the  outer  side  of  the  bleeding  nostril  is  found  ineffective, 
the  nostril  may  be  packed  with  cotton  saturated  with  a  5  per  cent, 
solution  of  antipyrin  or  a  1  :2000  solution  of  adrenalin. 

For  permanent  relief,  and  to  prevent  a  recurrence  of  the  hem- 
orrhage, adenoids  should  be  removed  and  an  excoriated  or  ulcerated 
septum  cauterized  with  a  50  per  cent,  solution  of  silver  nitrate.  If 
the  ulcer  is  first  cleaned  with  plain  water,  ordinarily  but  one  or  two 
appUcations  of  the  silver  solution  will  be  required.  Spraying  the 
affected  side  with  a  1  per  cent,  solution  of  ichthyol  in  liquid  albolene 
will  hasten  the  healing  process.  As  the  ichthyol  is  not  soluble  in  the 
oil,  the  mixture  should  be  well  shaken  before  using. 

THROAT  EXAMINATION 

In  order  to  examine  the  throat  of  a  young  child  quickly  and  thor- 
oughly it  is  necessary  that  he  be  held  in  a  proper  position  in  front  of 
and  at  the  right  side  of  the  attendant,  supported  by  her  left  arm 
beneath  the  buttocks.  Her  right  arm,  which  is  thus  left  free,  is  passed 
around  the  child,  binding  his  arms  to  his  sides.  The  child's  head 
rests  against  the  shoulder  of  the  attendant.  The  physician  places 
his  left  hand  on  the  child's  head  to  steady  it,  and  with  the  tongue- 
depressor  or  teaspoon  in  his  right  hand,  with  the  child  in  perfect  control, 
presses  the  tongue  downward  so  that  it  will  not  obscure  the  field  of 
vision.     In  handling  an  older  and  stronger  child,  it  is  best  to  bind  the 


272  THE    PRACTICE    OF    PEDIATRICS 

arms  to  the  sides  with  a  large  towel  or  small  sheet.  The  most  satis- 
factory view  can  be  obtained  by  daylight  before  a  window.  If  the 
examination  is  made  in  the  evening,  a  lamp  or  taper  held  by  a  third 
person,  a  little  above  and  behind  the  attendant's  right  shoulder,  will 
furnish  satisfactory  illumination.  The  head-mirror  should  be  used  for 
children  who  are  too  ill  to  be  taken  out  of  bed,  the  reflection  from  a 
lighted  lamp  or  candle  being  sufficient.  The  various  electrical  devices 
which  may  be- carried  in  the  pocket  are  very  useful  in  throat  examina- 
tion of  children. 

PERSISTENT  COUGH 

I  have  had  occasion  to  examine  and  treat  manj'-  children  who 
were  brought  to  me  because  of  a  "cough  "  which  had  not  been  controlled 
by  the  measures  employed.  The  history  is  usually  only  that  of  a  per- 
sistent cough.  This  may  be  irritating  in  character,  keeping  the  child 
awake  at  night,  or  it  may  be  paroxysmal,  the  attacks  being  more  severe 
when  the  child  is  lying  down.  Many  times  the  paroxysms  are  so  severe, 
particularly  at  night,  that  whooping-cough  is  suspected  because  of  the 
absence  of  chest  signs. 

Types  of  Cough. — While  we  hear  much  of  the  cough  of  teething, 
the  "stomach  cough,"  the  "nervous  cough,"  and  the  "habit  cough," 
it  has  never  been  my  lot  to  see  a  case  in  which  the  cough  was  not  con- 
nected in  some  way  with  the  respiratory  tract.  Thorough  examination 
of  these  cases,  perhaps  repeated  examinations,  will  be  required  before 
the  site  of  the  trouble  is  definitely  located,  when  it  will  invariably  be 
found  somewhere  between  the  anterior  nares  and  the  thorax.  The 
"stomach  cough,"  the  "nervous  cough,"  or  the  "teething  cough"  for- 
merly stood  for  the  persistent  cough  which  could  not  be  accounted 
for  by  physical  examination  of  the  chest  or  by  mere  inspection  of  the 
throat.     They  are  frequently  referred  to  by  the  older  writers. 

An  adherent  pleura  and  enlarged  tonsils  without  adenoids  are  ac- 
countable for  a  very  small  number  of  these  cases.  An  elongated 
uvula,  to  which  these  obscure  coughs  have  also  been  attributed,  is 
very  rarely  a  cause. 

Adenoid  Vegetations. — An  immense  majority  of  these  obscure  coughs 
in  children  are  due  to  adenoid  vegetations,  with  or  without  enlarged 
tonsils.  A  child  with  such  a  cough  may  have  the  typical  adenoid  face, 
mouth-breathing,  and  other  signs  referred  to  (see  Adenoids,  page  293) , 
or  these  symptoms  may  be  entirely  absent.  It  is  the  latter  type 
of  case  that  is  particularly  puzzling  and  apt  to  be  overlooked.  On 
account  of  the  absence  of  mouth-breathing  and  other  symptoms  of 
nasal  obstruction,  the  possibility  of  adenoid  vegetations  has  been 
ignored.  In  these  cases  careful  inquiry  will  usually  elicit  the  his- 
tory of  frequent  colds,  or  what  is  styled  "catarrh"  (as  there  is  more 
or  less  serous  discharge  from  the  nose),  or  the  statement  that  the  child 
"takes  cold  in  the  head  easily."  Digital  examination  of  the  nasopharyn- 
geal vault  will  reveal  a  fringe  of  soft  adenoid  growth  at  the  upper 
portion  of  the  posterior  pharyngeal  wall,  not  large  enough  to  pro- 


FAUCITIS  273 

duce  obstruction,  but  actively  secreting.  This  secretion,  if  not  profuse, 
is  partially  evaporated  in  the  nostrils,  or  if  profuse,  is  discharged  from 
the  nostrils  or  passes  backward  over  the  posterior  pharyngeal  wall, 
thus  provoking  cough,  when  the  child  is  up  and  about.  When  the 
child  rests  on  his  back,  the  secretion  naturally  flows  over  the  posterior 
pharyngeal  wall,  and  induces  cough.  Time  and  again  I  have  relieved 
the  most  obstinate  cough  by  cureting  and  removing  this  sponge- 
like tissue. 

Illustrative  Case. — In  the  case  of  one  patient,  a  boy  two  years  of  age,  who  had 
been  coughing  hard  for  ten  days  with  paroxysms  and  vomiting,  a  diagnosis  of 
pertussis  had  been  made  both  by  a  member  of  the  family  who  had  seen  many  cases 
of  whooping-cough,  and  also  by  myself.  Adenoids  were  found  to  be  present  in  a 
slight  degree.  Their  removal  was  accomplished,  with  the  idea  of  making  the 
coughing  attacks  less  severe,  when,  greatly  to  our  surprise,  the  coughing  ceased 
at  once,  not  a  paroxysm  occurring  after  the  growth  was  removed.  The  cough  was 
due  to  the  adenoid  vegetations  and  not  to  pertussis. 

Adherent  Pleura. — Adherent  pleura,  non-tuberculous,  as  previously 
mentioned,  is  occasionally  a  cause  of  persistent  cough.  Autopsies  upon 
•children  who  have  died  with  non-respiratory  diseases  often  show  these 
pleuritic  adhesions,  which  are  not  suspected  during  life.  A  little  girl 
twelve  years  of  age  was  brought  to  me  because  of  a  persistent  cough. 
The  child  was  otherwise  well  and  gaining  in  weight.  She  had  been 
treated  with  expectorants,  cod-liver  oil,  and  the  usual  other  medication, 
without  avail.  The  cough  remained  unchanged  and  was  influenced 
only  by  opiates.  A  very  careful  physical  examination  revealed  friction 
rales,  covering  an  area  the  size  of  a  half-dollar,  at  the  base  of  the  right 
lung,  adjacent  to  the  spine.  They  were  heard  only  on  forced  inspiration 
and  had  been  overlooked  in  the  previous  examination.  The  case  had 
been  diagnosed  as  one  of  "nervous  cough." 

Tracheal  Cough. — Tracheitis  will  produce  a  severe  and  intract- 
able cough,  with  no  signs  in  the  chest.  These  cases  frequently  follow 
attacks  of  true  influenza,  or  the  cough  may  be  present  during  the 
active  period  of  the  disease.  If  the  child  is  old  enough,  he  will  aid 
us  by  referring  to  the  sense  of  discomfort  and  tightness,  which  exists 
over  the  upper  portion  of  the  chest.  Sometimes  the  sensation  will 
be  described  as  a  burning  which  is*  located  directly  over  the  trachea. 

Tuberculosis. — Incipient  tuberculous  infiltration  in  any  portion  of 
the  lungs  or  pleura  may  produce  persistent  cough.  Thorough  physical 
examinations  and  careful  observation  of  all  the  cases,  with  the  von 
Pirquet  test,  will  make  a  diagnosis  possible. 

Pertussis. — Pertussis  without  the  whoop  or  vomiting  may  cause  a 
persistent  cough,  spasmodic  in  character.  It  runs  its  course  and  sub- 
sides in  from  four  to  eight  weeks.  A  diagnosis  is  possible  only  when 
there  is  a  history  of  exposure  to  the  disease,  or  when  another  member 
of  the  family  has  an  unquestionable  attack.  The  treatment  of  the 
various  conditions  producing  cough  is  referred  to  under  their  respective 
headings. 

FAUCITIS 

By  the  term,  faucitis,  we  understand  an  inflammation  of  that  por- 
tion of  the  mucous  membrane  of  the  buccal  cavity  situated  posteriorly 
18 


274  THE    PRACTICE    OF    PEDIATRICS 

to  the  soft  palate  and  the  anterior  pillars  of  the  fauces,  including 
both  the  anterior  and  posterior  pillars,  the  tonsils,  and  the  pharyngeal 
vault.  The  inflammatory  process  is  superficial,  involving  the  mucous 
membrane  only,  so  that  the  tonsils  are  involved  only  to  the  extent 
of  the  mucous  membrane. 

Faucitis  is  always  present  in  scarlet  fever,  usually  to  a  marked 
degree.  In  measles  it  is  also  present,  but  less  intense  in  its  mani- 
festations. Its- most  frequent  appearance  is  in  connection  with  a  sum- 
mer cold.  Every  year,  in  late  May  and  June,  I  am  called  upon  to  treat 
a  great  many  such  cases.  The  symptoms  always  comprise  cough, 
which  is  dry  and  ineffective,  and  a  slight  fever — from  100°  to  101°F. 
The  child  complains  of  sore  throat,  and  has  some  discomfort  on  swal- 
lowing. Upon  inspection,  an  intense  inflammation  will  be  noticed, 
involving  the  entire  visible  mucous  membrane.  In  many  cases  the 
inflammation  extends  downward  and  involves  the  larynx,  which  fact 
will  be  indicated  by  the  hoarse,  croupy  character  of  the  cough.  The 
condition  is  usually  the  result  of  a  mixed  infection,  with  the  strepto- 
coccus predominant.  The  entire  illness  is  ordinarily  of  three  or  four 
days'  duration. 

Treatment. — The  condition  is  best  relieved  by  a  purgative  of  rhu- 
barb and  soda — 3  grains  of  powdered  rhubarb  and  3  grains  of  soda  for 
a  child  from  two  to  five  years  of  age.  To  a  child  under  two  years 
of  age  1  to  3  grains  of  rhubarb  and  1  to  2  grains  of  bicarbonate  of  soda 
may  be  given.  This,  in  the  case  of  a  child  from  one  to  three  years  of 
age,  is  followed  by  a  tablet  or  powder  of  tartar  emetic,  }-^o  grain, 
powdered  ipecac,  3'^o  grain,  and  chlorate  of  potash,  1  grain,  at  two- 
hour  intervals.  Older  children,  three  years  and  over,  receive  2  to  3 
grains  of  chlorate  of  potash,  3'^o  grain  of  tartar  emetic,  and  3<^o 
grain  of  ipecac  at  two-hour  intervals — 6  doses  in  twenty-four  hours. 

PHARYNGITIS 

Inflammation  limited  to  the  posterior  pharyngeal  wall  is  of  rather 
infrequent  occurrence  in  young  children.  When  thus  affected,  the 
parts  present  a  reddened,  granular  appearance.  In  the  cases  which 
have  come  under  my  observation  such  a  condition  has  always  been 
associated  with  digestive  disturbances.  The  tongue  is  usually  coated, 
and  the  breath,  foul.  A  dry  cough  and  frequent  attempts  at  clearing 
the  throat  are  the  usual  symptoms.  The  temperature  is  rarely  above 
101  °F.  The  condition  is  to  be  distinguished  from  the  pharyngitis 
which  occurs  as  a  result  of  microbic  infection,  in  that  only  the  pos- 
terior wall  is  involved,  the  adjacent  structures  remaining  unchanged. 
The  tonsils  and  pillars  of  the  fauces  and  the  soft  palate  present  a 
normal  appearance. 

Treatment. — The  treatment  is  to  reduce  the  diet  for  a  few  days  to 
cereal  gruels, — barley,  rice,  or  wheat, — or  to  chicken  or  mutton 
broth.  Calomel,  3d!o  grain,  with  1  grain  of  rhubarb,  given  after  feed- 
ings, three  times  a  day  for  three  days,  will  promptly  relieve  the 
condition. 


ACUTE  RETROPHARYNGEAL  ABSCESS  275 

RETROPHARYNGEAL  ADENITIS 

Retropharyngeal  adenitis,  as  the  name  impHes,  is  an  inflammation 
of  one  or  more  of  the  glands  situated  posterior  to  the  pharynx,  between 
the  pharyngeal  and  prevertebral  muscles. 

Symptoms. — Pain  and  difficulty  in  swallowing  are  always  present. 
Other  symptoms  are  fever — 100°  to  103°F. — and  loss  of  appetite.  The 
patient  often  holds  the  head  toward  the  affected  side,  so  as  to  relax  the 
muscle  tension  caused  by  the  tumor.  If  the  adenitis  is  situated  low 
down,  disturbance  of  the  voice  (cracked  voice)  and  respiratory  obstruc- 
tion may  result. 

Diagnosis. — In  an  acute  case  inspection  of  the  throat  will  usually 
show  a  swelling  at  the  right  of  the  median  line.  If  situated  low  down 
on  the  posterior  pharyngeal  wall,  the  adenitis  may  escape  detection. 
Upon  digital  examination,  instead  of  a  smooth,  flat  surface,  the  finger 
encounters  an  elevated,  rounded  mass,  which  should  not  be  mistaken 
for  an  unduly  prominent  cervical  vertebra. 

Prognosis. — The  glands,  as  a  rule,  suppurate,  forming  a  retro- 
pharyngeal abscess.  This,  however,  does  not  invariably  follow. 
I  have  seen  several  cases  in  which  the  adenitis  subsided  without 
suppuration. 

Treatment. — The  treatment  must  be  both  local  and  constitutional. 
Local  treatment  consists  in  cleanliness.  The  mouth  should  be  washed 
with  a  saturated  solution  of  boric  acid  after  each  feeding.  lodids, 
in  treating  adenitis  in  children,  I  have  found  of  questionable  service. 
More  is  accomplished  by  suitable  diet  and  plenty  of  fresh  air. 

ACUTE  RETROPHARYNGEAL  ABSCESS 

Acute  retropharyngeal  abscess  is  the  result  of  an  infection  of 
one  or  more  of  the  retropharyngeal  lymph-nodes  which  form  a  chain 
on  either  side  of  the  median  line,  posterior  to  the  pharynx,  and  be- 
tween the  pharyngeal  and  the  prevertebral  muscles. 

Location. — The  abscess  is  most  frequently  situated  to  the  right  of 
the  median  line.  It  may  be  located  high  in  the  pharynx,  so  as  to  be 
plainly  visible  when  the  mouth  is  well  opened,  or  it  may  be  placed  low, 
posterior  to  the  larynx  and  upper  trachea.  Usually  the  abscess  points 
anteriorly  into  the  throat.  It  may  point  both  externally  and  internally. 
In  a  large  number  of  cases  I  have  not  seen  one  that  pointed  externally 
only. 

Age  of  Patients. — Retropharyngeal  abscess  is  preeminently  a 
disease  of  infancy.  The  retropharyngeal  lymph-nodes  are  said  to 
disappear  at  the  third  year.  I  have  not  seen  a  case  in  a  child  over 
three  years  of  age. 

Etiology. — Any  active  infection  of  the  throat  may  cause  the  dis- 
ease. It  may  occur  without  our  knowledge  of  any  infectious  process 
having  been  present.  All  throats  continuallj^  harbor  pathogenic 
bacteria,  which  may  infect  the  retropharyngeal  lymph-nodes. 


276  THE    PRACTICE    OF    PEDIATRICS 

It  has  not  been  my  observation  that  retropharyngeal  abscess  is 
a  common  sequel  of  diphtheria  and  the  exanthemata. 

Symptoms. — I  agree  with  Morse  and  others  who  state  that  these 
cases  are  usually  overlooked — erroneously  diagnosed.  They  are  fre- 
quently diagnosed  as  cases  of  adenoids,  and  the  removal  operation  is 
advised.  It  is  a  mistake  to  lay  down  too  definite  a  symptomatology 
of  a  condition  that  lends  itself  to  widely  varying  symptoms.  In  de- 
scribing the  disease  writers  tell  us  that  the  patient  holds  the  head  in  a 
characteristic  position, — backward  and  toward  the  affected  side, — 
that  the  breathing  is  noisy  and  stertorous  in  character,  that  there  is 
difficulty  in  swallowing,  that  there  are  enlarged  lymph-glands  at  the 
angle  of  the  jaw,  that  there  is  usually  a  high  fever,  and  that  a  bulging 
of  one  side  of  the  posterior  pharyngeal  wall  is  usually  visible.  It  is 
exceedingly  rare  to  find  this  combination  of  symptoms.  There  are 
two  diagnostic  symptoms  that  are  present  in  all  cases — difficulty  in 
swallowing  and  a  persistently  changed  voice — a  so-called  cracked,  high- 
pitched  voice.  These  symptoms  should  lead  one  to  suspect  retro- 
pharyngeal adenitis  or  abscess,  and  the  finger  examination  determines 
which  condition  is  present.  If  adenitis  exists,  a  rounded,  hard  tumor 
will  be  felt ;  if  an  abscess  has  formed,  a  soft,  fluctuating  tumor  will  be 
detected.  This  may  be  placed  so  high  in  the  pharyngeal  vault  as  to 
be  plainly  seen  through  a  wide-open  mouth,  or  it  may  be  low  and  out  of 
sight  in  ordinary  examination.  There  is  a  variation  of  at  least  two 
inches  in  the  possible  location  of  the  abscess,  and  this  fact  accounts  for 
the  varying  symptomatology.  The  difficulty  in  swallowing  interferes 
greatly  with  nursing,  and  should  always  lead  the  physician  not  only 
to  inspection,  but  also  to  digital  examination  of  the  throat. 

Illustrative  Cases. — A  baby  nine  months  of  age  had  been  under  treatment  in 
one  of  the  outdoor  clinics  of  New  York  City.  A  diagnosis  of  adenoids  had  been 
made  and  a  day  appointed  for  the  operation.  The  mother,  wishing  to  have  the 
diagnosis  of  adenoids  confirmed,  brought  the  child  to  the  Babies'  Hospital.  The 
symptoms  of  mouth-breathing,  nasal  voice,  and  slight  difficulty  in  swallowing  had 
been  present  for  a  couple  of  weeks.  There  was  no  characteristic  position  of  the 
head,  no  rigidity  of  the  neck,  no  superficial  enlargement  of  the  lymphatic  glands. 
Inspection  of  the  throat  disclosed  a  bulging  forward  of  the  soft  palate  on  the  right 
side.  A  digital  examination  revealed  a  round,  fluctuating  mass,  the  size  of  a 
hickory-nut.  It  was  found  high  on  the  posterior  pharyngeal  wall  and  almost 
entirely  covered  by  the  soft  palate.     No  adenoids  were  present. 

A  baby  two  years  of  age  had  been  ill  for  a  week  with  tonsillar  diphtheria  and 
was  thought  to  be  recovering,  when  suddenly  the  voice  became  hoarse  and  croupy, 
with  gradually  increasing  dyspnea.  Both  expiratory  and  inspiratory  obstruction 
were  present,  such  as  we  expect  in  laryngeal  diphtheria,  and  the  attending  physician, 
an  excellent  practitioner,  naturally  concluded  that  the  diphtheric  process  had 
extended  to  the  larynx.  There  was  stiffness  of  the  neck  but  no  nasal  obstruction 
(see  above).  There  was  slight  difficulty  in  swallowing.  Inspection  of  the  throat 
Avith  a  dim  light  revealed  nothing  but  the  enlarged  tonsils.  I  was  called  to  intubate, 
and  finding  the  respiratory  obstruction  sufficient  to  require  intubation,  I  pro- 
ceeded to  make  a  digital  examination,  as  is  my  custom  before  intubating.  I 
was  not  a  little  surprised  to  find  a  soft,  fluctuating  mass  low  down  in  the  pharyngeal 
wall,  extending  below  and  pressing  against  the  glottis.  The  abscess  was  opened, 
with  immediate  relief  to  the  obstruction. 

A  baby,  seven  and  a  half  months  of  age,  was  an  inmate  of  the  country  branch  of 
the  New  York  Infant  Asylum  during  my  service  in  that  institution.*     My  atten- 

*  The  case  was  reported  at  the  time  by  Dr.  Henry  E.  Tuley,  assistant  resident 
physician. 


ACUTE    RETROPHARYNGEAL    ABSCESS  277 

tion  was  first  called  to  the  child  because  of  the  difficulty  in  swallowing.  There 
was  very  little  obstruction,  but  the  voice  was  harsh,  hoarse,  and  croupy.  About  a 
month  previous  there  had  been  a  suppurating  submaxillary  adenitis.  On  examin- 
ing the  throat,  a  large  abscess  was  visible  on  the  right  pharyngeal  wall,  extending 
downward  as  far  as  could  be  seen.  This  case  afforded  my  first  experience  with  re- 
tropharyngeal abscess,  and  a  Denhard  gag  of  the  O'Dwyer  set,  which  should  never 
be  used  in  these  cases,  was  introduced  while  the  child  was  held  in  an  upright  posi- 
tion by  the  assistant.  While  I  was  feeling  for  the  thinnest  point  of  the  sac  for  a 
suitable  place  for  the  incision,  the  child  suddenly  stopped  breathing,  and  became 
limp  and  apparently  lifeless.  An  intubation  tube,  the  smallest  of  the  O'Dwyer 
set,  was  quickly  introduced  without  the  gag.  After  several  minutes  of  artificial 
respiration,  the  use  of  oxygen,  and  free  hypodermatic  stimulation  with  brandy, 
respiration  was  again  established.  The  first  inspiration  was  so  long  delayed 
that  we  had  almost  given  up  the  case  as  hopeless,  when  the  first  short  gasp  occurred. 
In  half  an  hour  the  child  had  sufficiently  recovered  to  allow  the  opening  of  the 
abscess.  This  was  done  without  a  gag,  with  the  tube  in  position.  After  a  copious 
discharge  of  pus,  the  tube  was  removed  and  the  child  recovered.  In  this  case  the 
suffocation  was  doubtless  due  to  the  introduction  of  the  gag  and  the  pressure  of 
the  finger,  which  forced  the  pus  into  the  lower  portion  of  the  sac  which  extended 
below  the  glottis,  where  the  pus  exerted  sufficient  pressure  to  prevent  the  entrance 
of  air. 

A  private  patient  one  year  old  had  diphtheria — laryngeal,  faucial,  and  tonsillar. 
Under  9000  units  of  antitoxin  and  intubation  satisfactory  progress  was  made,  and 
on  the  eighth  day  of  the  illness  the  tube  was  removed.  It  had  to  be  replaced  in  a 
few  minutes  because  of  returning  dj^spnea.  Upon  replacing  the  tube  an  abscess 
was  found  in  the  right  posterior  pharyngeal  wall,  pressing  upon  and  extending 
below  the  larynx.  The  presence  of  the  tube  had  prevented  the  recognition  of 
the  abscess.  Upon  determination  of  the  cause  of  the  obstruction  the  abscess  was 
evacuated,  but  the  marked  edema  of  the  glottis  still  caused  considerable  respirator 
obstruction,  and  the  tube  was  required  for  two  weeks  longer.  The  child  made  a 
perfect  recovery. 

The  above  cases  are  cited  in  detail  in  order  that  the  reader  may 
the  more  fully  realize  that  retropharyngeal  abscess  may  exist  with- 
out the  so-called  "characteristic  symptoms,"  and  also  to  emphasize 
the  fact  that  many  cases  have  been,  and  will  continue  to  be,  over- 
looked until  physicians  use  the  finger  as  an  aid  to  diagnosis  in  the 
diseases  of  the  upper  respiratory  tract.  It  is  to  be  remembered  that 
there  is  no  "characteristic  breathing"  and  no  "characteristic  posi- 
tion" of  the  head  with  retropharyngeal  abscess.  The  disease  is 
usually  secondary  to  retropharyngeal  adenitis  due  to  infection  from 
adjacent  diseased  structures.  Occasionally  the  abscess  points  outward 
and  requires  external  incision. 

Fever. — There  is  no  characteristic  temperature:  it  may  vary  a 
degree  or  two,  from  the  normal,  or  it  may  range  high — from  103°  to 
105°F. 

Treatment. — There  is  but  one  means  of  treatment — incision  and 
evacuation  of  the  pus.  In  order  that  this  may  be  done  it  is  neces- 
sary that  the  child  be  under  perfect  control.  The  arms  should  be  bound 
to  the  sides  with  a  large  towel  or  a  small  sheet,  securely  pinned.  The 
child  is  held  in  an  upright  position  on  the  lap  of  the  attendant,  who 
passes  his  left  arm  around  the  child,  while  his  right  hand  grasps  the 
forehead,  drawing  the  head  for  further  support  backward  against  his 
right  shoulder.  The  operation  should  be  performed  in  a  good  hght — 
either  reflected  light  from  a  head-mirror  or  direct  light  from  a  window. 
With  a  tongue  depressor  in  the  operator's  left  hand  holding  the  tongue 
out  of  the  way,  the  mouth  is  kept  open,  and  the  right  hand  is  free  to 


278  THE    PRACTICE    OF    PEDIATRICS 

make  the  incision,  for  which  an  ordinary  scalpel  is  used.  The  posterior 
portion  of  the  cutting  surface  should  be  guarded  with  adhesive 
plaster  wrapped  around  the  blade.  The  incision  should  be  made 
from  above  downward,  at  least  one-half  inch  in  length.  A  basin 
should  be  in  readiness  and  the  attendant  should  be  instructed  to 
invert  the  child  at  a  word  from  the  operator  as  soon  as  the  incision 
is  made.  This  allows  the  pus  and  blood,  which,  if  aspirated  into  the 
trachea,  may  produce  fatal  results,  to  stream  out  of  the  mouth.  While 
the  abscess  is  discharging  and  the  head  is  dependent,  the  clean  index- 
finger  of  the  operator  should  explore  the  cavity,  enlarge  the  opening, 
if  necessary,  and  remove  any  necrotic  tissue  that  may  be  present.  The 
case  should  be  carefully  watched  for  several  days,  as  the  opening  may 
close  before  resolution  is  complete,  particularly  if  it  has  not  been  en- 
larged with  the  finger.  Recovery  is  usually  complete  in  from  five 
to  seven  days. 

RETROPHARYNGEAL  ABSCESS— TUBERCULOUS  CARIES  OF  THE 
CERVICAL  VERTEBRA 

This  is  usually  wrongly  described  as  associated  with  idiopathic 
retropharyngeal  abscess.  The  tuberculous  condition  actually  is  a  part 
of,  and  results  from,  tuberculous  disease  of  the  spine,  which  will  be  re- 
ferred to  under  the  proper  headings. 

IRRIGATION  OF  THE  THROAT 

Indications. — In  cases  of  peritonsillar  abscess,  retropharyngeal 
abscess  after  operation,  or  sloughing  ulcerative  processes  in  the  throat, 
such  as  we  see  in  diphtheria  rarely,  but  with  comparative  frequency  in 
scarlet  fever,  irrigation  of  the  throat  with  hot  normal  salt  solution 
is  of  distinct  therapeutic  value.  The  relief  to  the  pain,  particularly 
in  quinsy  before  operation,  is  sufficient  to  warrant  this  treatment. 
Those  who  have  thus  treated  the  fetid,  sloughing  throat  of  scarlet  fever, 
for  example,  need  no  argument  as  to  the  possible  advantages.  Gargling 
is  a  measure  of  very  limited  usefulness  even  for  those  children  who  do 
it  well,  for  the  reason  that  the  solution  employed  scarcely  comes  in 
contact  with  the  postpharyngeal  wall  and  the  lateral  faucial  structures. 
For  a  great  majority  of  older  children,  and  all  young  children,  such  a 
method  is  practically  useless  so  far  as  the  cleansing  of  the  deeper 
faucial  structures  is  concerned. 

Cervical  adenitis,  acute,  persistent,  and  suppurative,  is  the  direct 
result  of  throat  infection.  Acute  suppurative  otitis  is  always  due  to 
throat  infection.  An  important  means  of  preventing  these  conditions, 
with  their  distressing  consequences,  is  an  effective  throat  toilet.  Often 
in  scarlet  fever  not  a  small  part  of  the  systemic  infection  after  the 
third  or  fourth  day  is  through  the  throat.  The  irrigation  should  be 
done  two  or  three  times  a  day  as  follows: 

Operation. — The  child  is  wrapped  in  a  sheet,  which  is  securely 
pinned,  binding  his  arms  to  his  sides.     He  rests  on  his  right  side,  with- 


THE    TONSILS  279 

out  a  pillow.  Directly  under  his  mouth  is  a  pus-basin  to  catch  the 
outflow.  A  new  fountain-syringe,  containing  a  hot  salt  solution,  120°F., 
is  suspended  about  three  feet  above  the  child's  body.  The  largest 
size  of  the  hard-rubber  rectal  tip  is  fastened  to  the  pipe  and  the  tip  is 
placed  between  the  child 's  teeth.  The  current,  interrupted  every  few 
seconds,  should  be  forcible  enough  to  increase  its  efficacy  as  a  cleansing 
agent,  the  volume  of  fluid  being  so  small  that  no  inspiration  of  the  water 
occurs. 

The  first  irrigations  will  arouse  more  or  less  rebellion  on  the  part 
of  the  patient,  and  but  one-half  pint  of  the  solution  need  be  used. 
With  older  children,  no  trouble  will  be  experienced  after  the  relief 
afforded  by  the  first  irrigation  is  appreciated.  In  treating  refractory 
young  children,  from  two  or  four  years  of  age,  the  assurance  that 
there  will  be  no  pain,  and  a  promise  of  reward,  will  reduce  the  struggling 
to  a  minimum.  It  is  not  to  be  expected  that  the  child  will  not  cough; 
in  fact,  a  moderate  amount  of  coughing  is  desirable,  as  it  dislodges  the 
pus  and  sloughing  tissue,  allowing  the  solution  to  cleanse  the  parts 
more  effectually. 

THE  TONSILS 

Anatomically,  the  lymphoid  structures  in  the  pharynx,  termed  ton- 
sils, consist  of  several  groups.  Of  these,  the  faucial  and  pharyngeal 
structures  are  clinically  of  most  importance. 

The  faucial  tonsils  are  situated  one  on  each  side  of  the  oropharynx, 
between  the  anterior  and  posterior  pillars  of  the  fauces.  The  tonsil 
is  roughly  ovoid,  and  in  early  life  about  2  cm.  thick,  the  longest  meas- 
urement being  the  vertical  diameter.  The  inner  surface  presents  many 
depressions  or  crypts.  These  are  most  numerous  in  the  upper  portion. 
Above  the  organ  there  is  a  larger  depression  called  the  supratonsillar 
fossa.  This  frequently  serves  as  a  pocket  for  the  development  of 
suppurative  inflammation.  On  its  outer  surface  the  tonsil  is  covered 
by  a  fibrous  capsule,  from  which  the  reticulum  of  connective  tissue 
supporting  the  lymphoid  structure  is  derived.  In  close  relation  to 
this  surface  is  the  ascending  palatine  artery.  The  internal  and  external 
carotid  arteries  are  normally  about  2  cm.  distant,  but  as  a  result  of 
inflammation  and  hypertrophy  in  the  tonsils,  these  vessels  may  be  less 
remote.  Branches  to  the  organs  are  derived  chiefly  from  the  ascending 
pharjmgeal  and  facial  arteries,  but  also  from  the  lingual  and  descending 
palatine.  Hemorrhage  following  operations  arises  principally  from 
the  ascending  palatine,  the  ascending  pharyngeal,  and  tonsillar  branches 
of  the  facial.     Operative  wounds  of  the  carotids  are  very  rare. 

The  phary7igeal  tonsil  is  a  single  structure,  occupjdng  the  posterior- 
pharyngeal  wall.  According  to  Piersol,  without  being  markedly  hyper- 
trophied,  it  may  encroach  upon  the  nasopharyngeal  space. 

The  tubal  tonsils  and  the  lingual  tonsils  are  developed  respectively 
at  the  Eustachian  orifices  and  over  the  posterior  third  of  the  tongue. 
Scattered  collections  of  the  same  tissue  unite  with  the  larger  masses 


280  THE    PRACTICE    OF    PEDIATRICS 

described,  and  form  an.  irregular  guardian-ring  encircling  the  upper 
part  of  the  pharynx. 

TONSILLITIS— ACUTE  FOLLICULAR  TONSILLITIS 

Tonsillitis  consists  in  an  inflammation  of  the  mucous  membrane 
and  glandular  structure  of  the  tonsil. 

Age. — No  age  appears  to  be  exempt.  I  have  seen  the  condition 
in  infants  three  or  four  weeks  old.  The  great  majority  of  the  cases,, 
however,  occur  between  the  second  and  twelfth  years. 

Etiology. — Tonsillitis  is  due  to  a  mixed  infection,  with  the  strepto- 
coccus predominating.  The  disease  is  exceedingly  infectious,  and  fre- 
quently occurs  in  epidemics. 

Predisposition. — One  attack  prediposes  to  another  by  preparing 
a  suitable  culture-field  in  the  crypts.  Children  in  whom  lymphatism 
is  prominent,  and  in  whom  the  glandular  structure  possesses  a  poor 
resistance,  are  the  most  susceptible. 

Pathology. — The  tonsils  undergo  considerable  enlargement,  and  the 
crypts  become  filled  with  exudate  consisting  of  epithelial  detritus,  mucus, 
pus,  and  bacteria.  Occasionally  the  exudate  covers  the  surface  of 
the  organ  in  the  form  of  a  pseudomembrane  similar  in  appearance  tO' 
that  occurring  in  diphtheria.  The  pathogenic  bacteria  most  frequently 
present  are  the  streptococcus,  staphylococcus,  and  pneumococcus. 
Of  these,  the  streptococcus  is  so  frequently  a  cause  of  the  inflammation 
that  in  many  epidemics  the  term  tonsillitis  has  been  superseded  by  the 
convenient  designation,  "streptococcus  sore  throat."  When  the  cel- 
lular infiltration  in  the  depths  of  the  tonsil  becomes  extreme,  sup- 
puration and  abscess-formation,  combined  with  severe  edema  of  the 
peritonsillar  tissue,  is  not  uncommon.  If  the  discharge  of  such  a  col- 
lection of  pus  is  not  spontaneous  or  else  obtained  by  early  incision, 
complete  destruction  of  the  parenchyma  and  the  formation  of  a 
retropharyngeal  abscess  may  result. 

Symptoms. — The  onset  of  tonsillitis  is  usually  sudden  and  may  be 
attended  by  a  chill.  In  a  few  of  my  cases  an  attack  has  been  ushered 
in  by  convulsions.  However,  the  usual  mode  of  onset  is  with  fever — 
101°  to  103°F.,  lassitude,  loss  of  appetite,  and  muscular  soreness. 
Young  children  may  show  difficulty  in  swallowing,  and  older  children 
may  complain  of  pain  in  the  throat.  Not  every  case  of  tonsillitis, 
however,  is  characterized  by  the  existence  of  such  pain.  Inspection 
shows  that  the  tonsils  are  swollen  and  reddened  and  perhaps  covered 
with  scattered,  light-colored,  cheesy  deposits.  In  some  instances  the 
local  signs  consist  only  of  the  swelling  and  redness;  in  other  cases  the 
cheesy  deposit  exists  as  an  early  manifestation.  The  spots  of  exudate 
may  remain  distinct  and  single,  or  they  may  coalesce,  forming  a 
pseudomembrane.  During  the  attack  the  patient  feels  decidedly  ill, 
and  often  gives  evidence  of  considerable  prostration.  The  tempera- 
ture ranges  from  103°  to  105°F.  SHght  sweUing  may  occur  in  the 
lymphatic  glands  at  the  angle  of  the  jaw,  but  this  is  usually  absent. 


TONSILLITIS ACUTE    FOLLICULAR    TONSILLITIS  281 

In  a  comparatively  small  percentage  of  cases  the  associated  adenitis 
will  be  very  pronounced.  A  great  deal  of  tenderness  of  the  glands, 
with  a  sore  throat,  is  a  suspicious  sign,  and  should  lead  one  to  ex- 
amine very  carefully  for  diphtheria. 

Duration. — An  uncomplicated  attack  of  tonsillitis  lasts  from  three 
to  five  days.  If  the  temperature  continues  for  a  longer  period  than 
six  days,  the  possibility  of  complications  should  be  considered. 

Prognosis. — The  prognosis  is  favorable;  when  uncomplicated,  the 
disease  is  never  fatal. 

Complications. — Cervical  adenitis,  otitis,  peritonsillar  (quinsy) ,  and 
retropharyngeal  abscess  are  the  most  frequent  secondary  conditions. 
Infrequent  complications  are  endocarditis,  pericarditis,  and  pyemia. 

Differential  Diagnosis. — Tonsillitis  must  be  differentiated  from 
tonsillar  diphtheria.  There  are  few  harder  problems,  and,  in  fact,  in 
many  cases,  early  in  the  attack,  the  solution  is  impossible  without  a 
bacteriologic  examination.  The  following  characteristics  of  the  average 
case  of  each  of  the  two  diseases  may  aid  us  in  differentiating : 

Tonsillitis. — Onset  sudden;  fever  high  at  onset — 102^*  to  105°F. 
Glands  at  the  angle  of  the  jaw  swollen  slightly,  if  at  all.  Exudation, 
follicular,  appearing  as  small  dots;  may  form  membrane  through 
coalescence. 

Tonsillar  Diphtheria. — Onset  gradual;  fever  usually  low  at  onset 
100°  to  102°F.  Lymphatic  glands  at  the  angle  of  the  jaw  considerably 
swollen.  Membrane  present  on  the  tonsil  appearing  in  thin,  grayish 
layers  which  gradually  become  thicker  and  more  extensive. 

Mixed  Infection. — A  case  of  mixed  infection  may  at  first  present  the 
picture  of  typical  tonsillitis.  The  temperature  may  vary  from  103° 
to  105°F.  Pain  upon  swallowing,  prostration,  and  loss  of  appetite 
may  exist  together  with  a  follicular  exudation.  Such  a  case  may  remain 
stationary  for  twenty-four  to  forty-eight  hours.  The  dots  then  coalesce, 
forming  a  firm  membranous  deposit;  the  lymph-nodes  at  the  angle  of 
the  jaw  enlarge;  and,  in  short,  both  the  clinical  manifestations  and 
the  bacteriologic  examination  show  that  we  have  to  deal  with  a  case 
of  diphtheria. 

These  cases  of  diphtheria  which  are  preceded  by  a  clinical  tonsillitis 
are  probably  the  most  dangerous.  The  primary  condition  is  diagnosed 
as  tonsillitis,  and  for  several  days  is  considered  to  be  only  a  tonsilHtis, 
in  spite  of  the  membranous  deposit  which  later  forms.  This  delay  in 
making  the  diagnosis  gives  abundant  opportunity  for  the  exposure  of 
other  children,  and  postpones  the  use  of  antitoxin,  rendering  the 
remedy,  when  finally  given,  of  little  or  no  avail.  It  is  my  rule  to 
consider  as  diphtheric  every  case  in  which  there  is  a  pseudomembrane 
on  the  tonsils,  and  to  treat  such  a  case  with  antitoxin  without  waiting 
for  a  bacteriologic  examination.  Furthermore,  when  there  are  other 
children  in  the  family,  I  invariably  quarantine  every  case  of  simple 
tonsillitis. 

Treatment. — ^Local  treatment  of  the  diseased  parts  in  tonsillitis  by 
spraying,  swabbing,  and  painting  has  been  of  very  little  service  in 


282  THE    PRACTICE    OF    PEDIATRICS 

my  hands,  particularly  in  dealing  with  children  under  four  years  of 
age.  When  the  patient  is  held  by  force  for  such  treatment,  thorough- 
ness is  impossible,  and  little  or  nothing  is  accomplished.  For  tract- 
able children  and  those  old  enough  to  understand  what  is  being  done, 
gargles,  sprays,  and  irrigations  are  useful  in  so  far  as  they  relieve  pain 
and  cleanse  the  diseased  parts.     A  useful  gargle  is  the  following: 

I^     Sodii  salicylatis, 
Sodii  biboratis, 

Sodii  bicarbonatis aa    gr.  xlv 

Essentise  menthse  piperitse 5  j 

Aquae q.  s.  ad    5  ij 

M.  Sig. — One  teaspoonful  in  one-half  glass  of  water  at  115°F.     Gargle 
entire  quantity  every  hour. 

A  useful  spray  is  the  following: 

I^     Acidi  borici gr.  Ix 

Aquae  menthse  piperitae Sviij 

M.  Sig. — Spray  throat  every  two  hours. 

Irrigation  of  the  throat  is  indicated  in  tonsillitis  not  only  for  pur- 
poses of  cleanliness,  but  because  of  the  relief  from  pain  which  it  affords. 
In  severe  tonsillitis  associated  with  much  swelling  and  consequent 
tension,  the  pain  upon  swallowing  is  often  excruciating.  For  the  irri- 
gation a  fountain-syringe  and  a  clean  tube  for  introduction  into  the 
mouth  are  needed.  The  child  may  lie  down  or  sit  up.  If  the  recum- 
bent position  is  maintained,  the  head  should  be  turned  to  one  side  so 
that  the  mouth  rests  over  a  pus-basin,  which  catches  the  water  as  it 
passes  out  during  the  irrigation.  If  the  irrigation  be  given  with  the 
patient  sitting  erect,  a  basin  held  under  the  chin  will  catch  the  water 
as  it  flows  from  the  mouth.  Two  pints  of  normal  salt  solution — one 
teaspoonful  of  salt  to  a  pint  of  water — at  115°F.  is  placed  in  the 
bag,  which  has  previously  been  warmed.  The  bag  is  then  held  two 
feet  above  the  child's  head,  and  the  solution  is  allowed  to  flow  in  a 
brisk  stream  against  the  swollen  parts  until  at  least  one  pint  has  been 
used.  The  irrigations,  if  found  acceptable,  may  be  repeated  in  from 
four  to  six  hours. 

It  is  advisable  to  begin  the  general  treatment  with  a  laxative.  One 
grain  of  calomel,  in  divided  doses  of  ^-q  grain  every  hour,  answers  well. 
The  food  should  be  reduced.  For  a  bottle-fed  patient  one-half  the 
quantity  of  the  usual  milk  mixture  should  be  given,  diluted  with  an 
equal  quantity  of  water.  The  fever,  if  high,  may  be  readily  controlled 
by  cool  sponging. 

The  only  drug  which  has  appeared  to  me  to  possess  any  signal  value 
for  internal  use  in  tonsillitis  is  chlorate  of  potash  given  in  the  dosage  of 
1  grain  at  two-hour  intervals  for  a  child  one  year  of  age ;  2  grains  at 
two-hour  intervals  for  a  child  two  years  of  age — 16  grains  in  twenty- 
four  hours ;  3  grains  at  the  same  interval  for  a  child  three  years  of  age — 
24  grains  in  twenty-four  hours.  I  rarely  give  more  than  3  grains  at 
two-hour  intervals  at  any  age.  I  have  used  chlorate  of  potash  in 
this  way  for  several  years,  and  I  have  never  been  able  to  associate 
its  action  with  kidney  complications  in  any  of  the  hundreds  of  cases 


PERITONSILLAR    ABSCESS    (qUINSY) 


283 


in  which  I  have  used  it.  This  drug  is  usually  given  in  solution  with 
simple  elixir  and  water  or  syrup  of  raspberry  and  water. 

Children  who  have  repeated  attacks  of  tonsillitis  should  have  the 
tonsils  enucleated  regardless  of  their  size,  as  diseased  tonsils  are  portals 
of  infection  and  a  source  of  ever-present  danger. 

Cold  compresses  (see  Fig.  26)  applied  to  the  throat  are  of  aid  to 
older  children,  who  can  appreciate  the  necessity  of  this  measure.  This 
form  of  treatment  is  described  in  detail  under  the  management  of  acute 
catarrhal  laryngitis.     (See  p.  290.) 


PERITONSILLAR  ABSCESS  (QUINSY) 

The  seat  of  a  peritonsillar  abscess  is  in  the  cellular  tissue  about  the 
tonsil,  and  the  condition  is  due  to  an  invasion  of  the  parts  by  patho- 
genic   bacteria,    among 

which  the  streptococcus  is    l^^"~"  '  '  '     '^     ~    - '    '■'  "^ 

most  frequently  present. 
The  source  of  the  infecting 
agent  is  almost  invariably 
a  tonsil  more  or  less  dis- 
eased. The  abscess  may 
form  above,  in  front  of,  or 
behind  the  tonsil.  The 
disease  is  seen  rather  infre- 
quently in  children.  I 
have  known  but  one  case 
in  a  child  under  six  years 
of  age.  Quinsy  is  usually 
preceded  by  tonsillitis. 
In  none  of  my  cases  has 
the  abscess  followed  diph- 
theria, scarlet  fever,  or 
measles. 

Symptoms. — The  child 
has  tonsillitis  with  the 
usual  symptoms,  and  in 
addition,  greatly  increased 
swelling  of  the  throat  and 

pain  upon  swallowing.  He  complains  of  pain  in  the  muscles  of  the  neck 
on  the  affected  side,  and  holds  the  head  toward  that  side.  A  fairly  early 
symptom  is  inability  to  open  the  mouth  to  the  usual  extent.  In  the 
average  case  inspection  reveals  a  reddened,  edematous  swelling,  slightly 
above  and  in  front  of  the  tonsil,  causing  a  forward  displacement  of 
the  uvula.  In  a  few  instances  I  have  seen  swelling  develop  behind 
the  tonsil,  in  which  case  the  tonsil  on  the  affected  side  is  displaced  for- 
ward and  appears  unduly  prominent.  A  case  of  this  type  is  very  apt 
to  be  overlooked  unless  a  digital  examination  is  carefully  made,  when  a 
soft,  fluctuating  swelling  will  readily  be  felt  behind  the  tonsil.     Speech 


Fig.  26. — Cold  compress  in  position. 


284  THE    PRACTICE    OF    PEDIATRICS 

is  interfered  with,  and  the  act  of  swallowing  is  carried  out  with 
great  discomfort.  Young  patients  will  go  for  several  days  with  little 
or  no  nourishment  because  of  the  pain  occasioned  by  the  taking  of  food. 

Treatment. — The  treatment  is  by  incision.  This  step,  however, 
should  not  be  taken  until  the  abscess  is  fully  developed.  If  the  inci- 
sion is  made  too  early,  it  has  in  my  cases  invariably  closed  and  required 
reopening.  This  closure  sometimes  occurs  even  after  a  timely  opera- 
tion, because  when  too  small  an  incision  is  made,  the  contraction  of  the 
abscess  wall  necessarily  following  the  free  discharge  of  pus  and  blood 
effectually  closes  the  opening. 

For  operation  the  patient  should  be  wrapped  in  a  large  towel  or 
sheet  with  the  arms  securely  bound  to  the  sides.  He  should  sit  in  an 
upright  position  on  the  lap  of  the  attendant,  against  whose  right 
shoulder  his  head  rests.  The  left  arm  of  the  attendant  is  passed  around 
the  patient,  holding  him  firmly,  while  the  right  hand  grasps  his  fore- 
head. A  Denhard  gag  of  the  O'Dwyer  set  should  be  used  to  hold  the 
mouth  open.  Either  by  the  use  of  reflected  light  from  a  head-mirror, 
or  with  the  patient  facing  a  window,  the  operator,  using  a  guarded 
bistoury,  makes  a  free  incision  in  the  abscess  from  above  downward. 
The  escape  of  a  considerable  amount  of  blood  usually  follows  the  with- 
drawal of  the  knife.  Oftentimes  more  blood  than  pus  is  discharged. 
This  is  particularly  apt  to  be  the  case  if  the  abscess  is  opened  early. 

It  is  interesting  to  note  that  the  cases  which  open  spontaneously 
never  heal  spontaneously.  After  making  a  free  incision  it  is  my  custom, 
during  my  daily  visits  immediately  after  the  operation,  to  prevent  a 
closure  of  the  wound  by  passing  into  it  a  director,  moving  this  up  and 
down  to  break  up  any  beginning  granulations.  With  free,  uninter- 
rupted drainage  the  case  is  usually  well  in  from  three  to  five  days. 

With  the  exception  of  a  saline  laxative,  which  should  be  given  early 
in  the  attack,  internal  medication  is  valueless.  Two  drams  of  Rochelle 
salts  or  6  ounces  of  a  solution  of  citrate  of  magnesia  are  usually  ordered. 
Other  treatment  is  directed  to  the  comfort  of  the  patient.  An  ice-bag 
applied  externally  before  operation  may  be  acceptable.  Our  greatest 
means  of  relief,  however,  is  afforded  by  the  use  of  the  hot  saline  irriga- 
tion, and  the  hot  gargle  where  practicable.  But  few  children  can 
gargle  well,  however,  so  that  ordinarily  this  measure  is  best  dispensed 
with.  With  the  few  cases  where  it  is  practicable,  I  have  found  the 
following  prescription  and  method  of  use  of  service : 

I^     Sodii  bicarbonatis gr.  xlv 

EssentiEe  menthse  piperita 5j. 

Aquae q.  s.  ad     Sij 

M.  Sig. — Add  1  teaspoonful  to  6  ounces  of  water  at  120°F.  and  gargle 
entire  quantity  every  half  hour. 

The  pain  occasioned  by  gargling  is  another  objection  to  its  practice 
by  children.  A  far  more  effectual  means  of  relieving  pain  in  this  dis- 
ease, and  one  which  causes  no  effort  nor  distress  whatever,  and  which 
gives  astonishing  relief,  is  a  saline  irrigation  which  is  prepared  and 
given  as  follows:  A  heaping  teaspoonful  of  salt  is  added  to  one  pint 


Vincent's  angina  285 

■of  water  at  120°F.  This  is  placed  in  a  fountain  syringe  which  is  previ- 
ously warmed.  A  towel  is  placed  around  the  patient's  neck,  to  pro- 
tect the  clothing.  The  basin  is  held  under  the  mouth,  to  catch  the 
drainage.  With  everything  in  readiness,  the  bag  containing  this 
solution  being  hung  from  two  to  three  feet  higher  than  the  child 's  head, 
the  end  of  the  rubber  tube,  a  part  of  every  fountain  syringe,  without  the 
hard  rubber  tip  attachment,  is  placed  in  the  child 's  mouth  and  the  hot 
solution  is  allowed  to  flow  against  the  inflamed  surfaces  until  the  entire 
pint  has  been  used,  pressure  being  maintained  upon  the  tube  so  that 
the  flow  will  not  be  too  free.  During  the  first  irrigation  or  two,  there 
will  be  more  or  less  coughing,  and  the  child  may  have  to  rest  after  an 
interval  of  a  few  minutes.  After  he  becomes  accustomed  to  the  pro- 
cedure the  entire  pint  may  be  used  without  intermission.  The  irriga- 
tion may  be  repeated  every  hour  and  may  be  used  as  well  after  as  before 
operation.  When  once  the  child  experiences  the  relief  afforded,  there 
will  be  no  trouble  in  repeating  the  irrigation. 

VINCENT'S  ANGINA 

In  Vincent's  angina  there  is  an  ulcer  of  the  tonsil  of  varying  size. 
It  may  involve  the  whole  tonsil  or  a  very  small  portion.  The  shape 
of  the  ulcer  is  irregular  with  overhanging  edges  in  advanced  cases, 
in  appearance  not  unlike  a  syphilitic  lesion.  The  ulcer  is  of  varying 
depth,  usually  not  more  than  a  quarter  of  an  inch  at  the  deepest  part. 
The  sloughing  bed  of  the  ulcer  gives  the  appearance  of  a  membranous 
deposit. 

Etiology. — Vincent's  angina  is  an  infection  in  which  two  forms  of 
parasites  may  be  isolated,  one  a  fusiform  bacillus  and  the  other  a 
spirillum.  They  are  always  associated.  These  are  also  found  in 
ulcerative  stomatitis. 

The  bacillus  is  a  slender  rod  measuring  from  6  to  12  /i  long 
pointed  at  each  end,  gram  negative,  and  is  not  motile.  The  spiril- 
lum generally  has  from  3  to  10  convolutions,  is  actively  motile,  and 
gram  negative.  These  sometimes  appear  in  a  mixed  infection  with 
diphtheria. 

Symptoms. — The  symptoms  are  not  at  all  severe,  usually  a  slight 
rise  in  temperature,  100  to  102  with  perhaps  moderate  swelling  of  the 
lymph  nodes  on  the  affected  side.  There  is  often  an  accompanying 
stomatitis  which  may  be  the  trouble  for  which  the  physician  is  con- 
sulted. That  there  is  an  involvement  of  the  tonsil  is  first  discovered 
during  the  examination  of  the  patient.  Very  severe  and  fatal  cases 
have  been  reported  but  these  are  surely  very  unusual. 

Diagnosis. — The  case  may  resemble  diphtheria  sufficientlj^  to 
require  that  a  culture  be  made.  A  differential  diagnosis  is  usually 
readily  made  by  a  microscopical  examination  of  a  smear  from  the  ulcer. 
The  bacilli  and  spirilla  do  not  grow  in  culture  media. 

Treatment. — The  medical  treatment  is  the  same  as  for  tonsillitis. 
If  there  is  an  adenitis,  a  cold  compress   (p.  290)  should  be  applied. 


286  THE   PRACTICE    OF   PEDIATRICS 

Locally,  tr.  iodine  or  peroxide  of  hydrogen  applied  twice  daily  to  the 
ulcer  appears  to  shorten  the  duration  of  the  disease. 

SEPTIC  SORE  THROAT  (MILK  BORNE)* 

Epidemic  sore  throat  due  to  an  infection  conveyed  by  milk  has 
been  of  frequent  occurrence  in  England  for  several  years  past. 

Since  the  Boston  epidemic  in  1911,  visitations  of  the  disease  have 
been  reported  from  various  sections  of  this  country.  Doubtless  out- 
breaks had  previously  occurred  but  had  not  been  recognized  as  an  en- 
tity. In  a  recent  epidemic  of  40  cases  in  which  the  author  saw  several 
patients  there  was  a  mortahty  of  15  per  cent. 

Age. — All  ages  are  susceptible,  the  greatest  number  of  cases  occur 
among  the  young,  as  would  be  expected. 

Etiology. — In  the  Boston  epidemic  of  1911  it  was  first  conclusively 
demonstrated  in  this  country  that  septic  sore  throat  is  a  distinct 
clinical  entity  due  to  the  streptococcus  conveyed  in  a  polluted  milk 
supply.  During  this  time,  and  at  subsequent  outbreaks,  an  examina- 
tion of  the  milk  source  led  to  the  discovery  of  an  epidemic  of  mastitis 
existing  among  the  cows  supplying  the  involved  community,  pus 
cells  being  found  on  several  occasions  in  the  milk.  That  the  dairyman 
acting  as  a  human  carrier  is  also  a  factor  in  infecting  the  milk  has  been 
proven  by  the  existence  of  a  number  of  cases  of  sore  throat  among 
dairy  employees,  one  of  whom  (in  an  epidemic)  showed  an  abundant 
growth  of  almost  pure  streptococci. 

Pathology. — A  general  redness  may  be  diffused  over  the  pharynx, 
tonsils  and  soft  palate  simulating  a  scarlet  fever  throat  or  small 
isolated  patches  of  exudation  in  the  tonsillar  crypts  may  make  it  re- 
semble an  acute  follicular  tonsillitis.  Later  an  extensive  pseudomem- 
branous exudate  may  strongly  suggest  diphtheria.  Both  tonsils  may 
be  involved  simultaneously,  but  more  frequently  one  is  infected  before 
the  other.  The  cervical  lymph-nodes  are  always  involved  to  some 
extent  and  occasionally  very  much  swollen,  terminating  in  suppura- 
tion in  the  severe  cases.  The  extension  of  the  inflammation  to  the 
deeper  tissues  about  the  neck  often  leads  to  a  diffuse  cellulitis  of  that 
region. 

Symptoms. — The  onset  of  the  septic  sore  throat  is  fairly  uniform 
in  its  manifestations.  It  is  usually  sudden  and  attended  by  a  chill  in 
the  great  majority  of  cases.  Nausea  is  also  a  frequent  accompaniment 
of  the  early  stages.  The  temperature  rises  rapidly  to  103  or  105  and 
in  the  more  toxic  cases  there  is  present  general  muscular  pain  and 
soreness  and  severe  headache.  A  marked  degree  of  prostration  is  pres- 
ent in  the  severe  cases.  The  first  period  of  the  disease  last  from  three 
to  five  days  and  a  rapid  recovery  may  follow  in  the  mild  cases  or  com- 
plications which  may  be  numerous  and  dangerous  may  ensue  and 
prolong  the  duration  indefinitely. 

*  Herman  Biggs,  N.  Y.  Medical  Record,  1915  presents  a  comprehensive  con- 
tribution on  Milk  Borne  Septic  Sore  Throat. 


ACUTE    CATARRHAL  LARYNGITIS    (SPASMODIC    CROUP)        287 

Complications. — Cervical  adenitis  with  possible  suppuration  and 
otitis  media  are  the  most  frequent  secondary  involvements  in  the 
young.  Peritonsillar  abscess,  nephritis,  polyarthritis,  pneumonia  and 
peritonitis  are  occasionally  seen,  especially  in  those  more  advanced  in 
years. 

Prognosis. — The  prognosis  is  better  in  children  and  young  adults 
than  in  those  who  are  more  advanced  in  years,  due  to  the  fact  that  they 
enjoy  a  comparative  freedom  from  the  above-mentioned  complica- 
tions. The  mortalities  in  recent  epidemics  according  to  the  literature 
have  varied  from  2  to  5  per  cent. 

Prophylaxis. — Pasteurization  of  all  milk  used  for  drinking  purposes 
will  prevent  the  establishment  of  the  disease.  Dairy  employees  should 
be  under  careful  medical  supervision. 

Treatment. — The  treatment  suggested  for  tonsillitis  should  be  car- 
ried out  here,  together  with  throat  irrigation  (p.  278)  and  supportive 
measures. 

Autogenous  vaccines  should  be  prepared  and  used  early  in  the 
disease. 

ACUTE  CATARRHAL  LARYNGITIS  (SPASMODIC  CROUP) 

In  acute  catarrhal  laryngitis  two  factors  are  operative:  the  local 
infection  causing  a  swelling  and  infiltration  of  the  laryngeal  mucous 
membrane,  and  the  laryngeal  spasm  which  is  apparently  excited  by 
the  local  process. 

Etiology. — The  disease  may  be  primary  or  secondary  to  inflamma- 
tory conditions  in  the  nasopharynx.  Exposure  to  cold  is  a  prediposing 
cause.  Rachitic  children,  if  they  develop  the  disease,  are  liable  to 
have  it  in  a  severe  form.  They  are  no  more  predisposed,  however, 
than  normal  children.  Adenoids  and  enlarged  tonsils  are  predisposing 
causes. 

Illustrative  Case. — A  case  which  demonstrates  the  possible  effects  of  sudden  cold 
occurred  at  the  New  York  Infant  Asylum  during  my  internship  in  that  institution. 
A  delicate  baby,  six  months  of  age,  was  exposed  for  a  few  minutes  on  a  very  cold, 
windy,  December  day,  with  no  head  covering  and  simple  ward  clothing.  Within 
an  hour  a  croupy  cough  had  developed,  and  in  three  hours  intubation  was  necessarj'. 

Pathology. — Early  in  the  attack  the  mucous  membrane  is  swollen 
and  free  from  secretion.  In  older  children,  in  whom  a  laryngoscopic 
examination  is  possible,  the  mucous  membrane  is  seen  to  be  intensely 
congested  and  dry.  When  resolution  begins,  the  parts  appear  glisten- 
ing and  edematous.  The  lesion  itself,  however,  is  never  sufficient  to 
produce  the  obstruction  to  inspiration  peculiar  to  these  cases,  as  the 
mucosa  is  probably  alone  involved. 

Symptoms. — The  onset  may  be  sudden  or  gradual.  Cases  of 
gradual  onset  usually  follow  an  acute  inflammatory  condition  of  the 
nasopharynx,  the  fauces  and  larynx  becoming  successively  involved 
over  a  period  of  perhaps  two  or  three  days  before  the  laryngitis  is 
well  marked.  The  temperature  at  the  onset  is  usually  not  high. 
One  of  the  early  symptoms  indicating  laryngeal  involvement  is  a  hard, 


288  THE    PRACTICE    OF    PEDIATRICS 

dry  cough,  croupy  and  "barking"  in  character.  The  croupy  cough 
increases  in  severity  toward  evening,  and  is  often  associated  with 
urgent  respiratory  obstruction. 

In  a  typical  case  with  sudden  onset  the  following  are  the  more  fre- 
quent symptoms:  the  child  retires  at  the  usual  hour  in  apparently 
good  health ;  a  few  hours  later  he  wakes  with  the  characteristic  cough, 
active  laryngeal  spasm,  cyanosis  and  labored  efforts  at  inspiration  in- 
volving dilatation  of  the  alae  nasi,  suprasternal  and  infrasternal  reces- 
sion, profuse  perspiration,  and  rapid  pulse.  The  expression  is  anxious, 
and  the  child  cries  in  fear.  The  temperature  is  variable,  but  usually 
elevated.  Expiration  is  usually  unimpeded.  Under  right  treatment 
the  symptoms  of  spasm  subside  and  do  not  recur  on  the  following 
night.  The  cough  which  persists  for  a  few  days,  subsides  under  proper 
treatment.  In  some  of  the  cases,  however,  the  course  is  not  so  favor- 
able ;  the  cough  continues,  becoming  stridulous,  every  inspiration  being 
accompanied  by  a  loud,  crowing  sound,  and  in  extreme  instances  the 
laryngeal  obstruction  due  to  the  swelling  and  laryngeal  spasm,  is  so 
severe  as  to  require  intubation.  In  my  experience,  however,  this  is 
very  rare,  as  I  have  had  to  intubate  but  one  child  with  catarrhal, 
non-membranous  croup — the  infant  already  referred  to. 

Differential  Diagnosis. — Acute  laryngitis  may  be  confused  with 
diphtheric  or  membranous  laryngitis.  (For  differentiation,  see  p. 
631.) 

Laryngismus  stridulus  may  be  mistaken  for  catarrhal  laryngitis. 
Differentiation  is  easy,  when  one  remembers  that  in  uncomplicated 
laryngismus  stridulus  there  is  no  cough,  and  that  the  laryngeal  spasm 
is  usually  associated  with  excitement,  fright,  or  some  other  nervous 
influence.  Furthermore,  laryngismus  stridulus  does  not  occur  as  a 
definite  acute  illness;  the  laryngeal  spasm,  mild  or  severe,  occurs,  as  a 
rule,  several  times  a  day  over  a  period  of  weeks  or  months.  The  con- 
tinuous obstruction,  always  associated  with  inflammatory  conditions 
of  acute  catarrhal  laryngitis,  is,  moreover,  absent  in  laryngismus. 

Retropharyngeal  adenitis  or  abscess  may  be  confused  with  catarrhal 
laryngitis.  Respiratory  obstruction  in  acute  laryngitis  is  apparent 
only  during  inspiration,  and  the  cough  and  dyspnea  are  usually  of 
sudden  onset.  Retropharyngeal  adenitis  and  abscess  are  characterized 
by  a  persistency  of  the  symptoms  while  the  disease  is  active.  Digital 
exploration  of  the  pharynx  makes  the  differentiation  final.  In  con- 
genital stridor,  the  stridor  is  relieved  by  stress  or  excitement,  the 
noisy  breathing  and  other  evidences  of  obstruction  being  worst  when 
the  child  is  quiet  or  asleep. 

Treatment. — In  the  treatment  of  catarrhal  laryngitis  in  children 
two  conditions  must  be  kept  in  mind :  First,  the  inflammatory  infiltra- 
tion and  dryness  of  the  parts,  producing  the  metallic  cough  and  the 
stridulous  breathing;  second,  the  laryngeal  spasm,  which  is  purely  a 
nervous  manifestation,  doubtless  due  to  irritation  of  the  terminal 
filaments  of  the  recurrent  laryngeal  nerves. 

By  no  means  every  case  of  laryngitis  in  children  develops  into  croup. 


ACUTE    CATARRHAL   LARYNGITIS    (SPASMODIC   CROUP)        289 

When  croup  is  present,  however,  we  know  that  its  existence  is  due  to 
the  association  of  laryngeal  spasm  with  congestion  and  inflammation. 
If  we  are  to  promote  quick  recoveries,  we  must  not  lose  sight  of  the 
important  nervous  element. 

Expectorants. — For  the  simple  coughs,  without  accompanying  in- 
terference with  respiration,  treatment  with  expectorants  and  steam 
is  of  great  service,  regardless  of  the  age  of  the  child.  This  treatment 
should  be  preceded  by  the  administration  of  a  full  dose — from  1  to  3 


Fig.  27. — Crib  prepared  for  steam  inhalation. 

teaspoonfuls — of  castor  oil.  To  a  child  under  one  year  of  age  a  tablet 
composed  of  tartar  emetic,  Hoo  grain,  with  powdered  ipecac  jy^o 
grain,  should  be  given  every  two  hours — 8  doses  in  the  twenty-four 
hours.  If  the  tablets  or  powders  are  not  available,  2  drops  of  syrup 
of  ipecac  may  be  given  instead.  To  a  child  from  one  to  two  years  of 
age  a  tablet  or  powder  composed  of  /-f  oo  grain  of  tartar  emetic,  3^o 
grain  of  powdered  ipecac,  and  3-^  grain  of  Dover's  powder  may  be  given 
at  two-hour  intervals — 8  doses  in  twenty-four  hours.  After  the  first 
19 


290  THE    PRACTICE    OF    PEDIATRICS 

day  the  treatment  should  be  resumed  early  in  the  morning,  so  that  by 
evening,  when  the  cough  and  spasm  are  most  severe,  the  full  influence 
of  the  drugs  may  be  secured.  From  the  third  to  the  sixth  year 
powder  or  tablet  composed  of  tartar  emetic,  }^o  grain,  powdered 
ipecac,  }4o  grain,  and  Dover's  powder,  ^i  grain,  should  be  given  at 
two-hours  intervals — 8  doses  in  twenty-four  hours.  At  least  8  doses 
of  one  of  the  above  prescriptions  should  be  given  daily  in  order  to  get 
the  full  benefit  of  the  drugs  employed.  If  the  Dover's  powder  pro- 
duces constipation,  this  ingredient  may  be  omitted  or  counteracted 
by  a  laxative.  Ordinarily  treatment  need  not  be  continued  more 
than  two  or  three  days.  In  case  the  attack  is  mild,  the  Dover's 
powder  should  be  omitted. 

Cold  Compresses. — In  the  treatment  of  older  children  the  ap- 
plication of  a  cold  compress  to  the  throat  is  a  valuable  local  measure. 
A  napkin  or  piece  of  old  linen  so  folded  that  there  are  at  least  six 
thicknesses  of  the  material,  should  be  moistened  with  cold  water  at 
60°F.,  wrung  thoroughly,  and  placed  against  the  neck,  under  the  jaw, 
so  as  to  extend  from  ear  to  ear.  Over  this  should  be  placed  a  piece 
of  oiled  silk  or  rubber  tissue  held  in  position  by  a  strip  of  thin  mus- 
lin or  cheese-cloth,  which  should  be  brought  together  at  the  ends  and 
fastened  at  the  top  of  the  head.  The  compress  should  be  changed 
every  thirty  minutes.  In  the  management  of  very  young  children 
this  measure  is  rarely  satisfactory,  for  the  reason  that  it  is  difficult 
to  force  the  child  to  allow  the  bandage  to  remain  in  place.  The  prac- 
tice of  placing  the  compress  around  the  neck,  as  is  often  done,  is  of 
no  value,  as  the  dressing  does  not  even  overlie  the  diseased  parts. 

Steam  Inhalations. — Steam  inhalations  are  effective  only  when  the 
patient  is  kept  in  an  inclosed  space.  Steam  diffused  throughout  the 
room  is  of  little  or  no  service.  The  easiest  and  most  practical  place  for 
the  child  is  in  its  crib,  which  should  be  covered  with  a  sheet.  An  open 
umbrella  may  be  substituted  when  a  crib  is  not  available.  Under  the 
umbrella,  which  rests  upon  the  bed,  lies  the  child,  and  covering  all  is  a 
sheet  pinned  to  the  umbrella.  If  preferred,  the  open  umbrella,  draped 
as  before,  may  be  placed  over  the  baby-carriage.  Any  means  or 
apparatus  is  adequate  which  will  furnish  steam  and  conduct  it  to  the 
inclosed  space.  The  Holt  croup  kettle  when  obtainable  is  always  to 
be  used.  The  steaming  may  be  continued  for  hours.  The  sheet 
should  be  removed  occasionally  for  a  few  moments,  in  order  to  allow 
a  change  of  air.  Usually  a  child  may  be  kept  under  the  tent  from 
twenty  minutes  to  one-half  hour  without  such  a  change.  The  tent 
is  seldom  so  close  as  to  prevent  all  ventilation. 

Calomel  Fumigations. — A  quicker  and  more  effectual  means  than 
the  treatment  with  steam  is  the  use  of  calomel  fumigations.  The 
patient  is  placed  under  a  tent  prepared  as  above.  Ten  grains  of 
calomel  are  placed  in  any  tin  receptacle,  which  rests  or  is  held  over  the 
flame.  The  Ermold  lamp,  made  especially  for  this  purpose,  is  recom- 
mended, although  the  ordinary  alcohol  lamp  used  for  warming  milk 
answers  every  requirement.     An  ordinary  kerosene  lamp  has  served 


TRAUMATIC   LARYNGITIS  291 

me  well  in  a  few  instances,  the  calomel  being  placed  in  the  cover  of  a 
tin  can  which  was  held  by  a  pair  of  pincers  over  the  top  of  the  lamp 
chimney.  Regardless  of  the  method  the  fumigation  must  be  con- 
stantly watched  by  some  competent  person,  so  as  to  avoid  the  possi- 
bility of  igniting  the  bedclothes.  When  the  fumes  begin  to  fill  the 
tent,  the  child  will  cough  considerably.  If  the  cough  continues  for 
more  than  a  few  minutes,  a  portion  of  the  vapor  should  be  permitted 
to  escape.  The  calomel  will  be  consumed  in  from  five  to  ten  minutes, 
depending  upon  the  degree  of  heat  used.  After  the  tent  is  filled  with 
the  vapor,  the  child  may  inhale  it  for  about  one-half  hour.  The 
vapor  produces  free  secretion  from  the  mucous  membrane  of  the  parts, 
and  local  depletion,  resulting  in  enlargement  of  the  lumen  of  the  larynx 
and  consequent  relief  of  the  symptom.  The  fumigations  may  be  re- 
peated after  an  interval  of  two  or  three  hours.  If  a  non-diphtheric 
case  I  have  rarely  had  to  repeat  the  inhalations  more  than  two  or 
three  times. 

Antispasmodics. — In  the  cases  of  sudden  onset,  in  which  the 
spasmodic  element  is  prominent  at  the  commencement  of  the  attack,  as 
indicated  by  the  high-pitched,  crowing  inspiration,  and  in  some  ex- 
treme cases  by  the  struggle  for  breath,  the  cyanosis,  the  stridor,  and 
the  infrasternal  recession,  the  above  treatment  will  not  avail.  We 
must  combine  an  expectorant  with  antispasmodic  drugs.  A  full  dose  of 
syrup  of  ipecac — one  to  two  teaspoonfuls,  or  sufficient  to  produce 
emesis — should  be  given  at  once.  If  vomiting  does  not  result  in 
twenty  minutes,  the  ipecac  should  be  repeated.  After  emesis  has 
taken  place,  the  antispasmodic  remedies  should  be  brought  into  use. 
Antipyrin  and  sodium  bromid  are  especially  effective  at  this  stage. 
Antipyrin  appears  to  have  a  direct  sedative  action  on  the  nervous  mech- 
anism of  the  larynx.  To  a  child  two  years  of  age  the  following  pre- 
scription may  be  given  : 

I^     Antipyrini gr.  j 

Sodii  bromidi gr-  ij 

Syrupi  ipecacuanhae ' n^ij-iij 

Aquae q.  s.  ad    3  j 

M.  Sig. — One  such  dose  every  two  hours — eight  doses  in  twenty-four 
hours. 

To  a  child  from  three  to  six  years  of  age  may  be  given: 

I^     Antipyrini gr.  ij 

Sodii  bromidi gr.  iv 

Syrupi  ipecacuanhae gtt.  iij 

Syrupi  rhei gtt.  xv 

Aquae q.  s.  ad    3 j 

M.  Sig. — One  such  dose  every  two  hours — eight  doses  in  twenty-four 
hours. 

TRAUMATIC  LARYNGITIS 

Traumatic  laryngitis,  although  a  very  rare  condition  in  children,  is 
occasionally  observed.  It  may  be  caused  by  the  inhalation  of  steam 
or  irritating  gases  or  the  aspiration  of  carbolic  or  other  strong  acids. 

I  once  saw  a  fatal  case  due  to  the  aspiration  of  pure  carbolic  acid 
by  a  child  three  years  of  age  who  was  given  a  teaspoonful  of  the  acid 


292  THE    PRACTICE    OF    PEDIATRICS 

by  a  five-year-old  sister.  As  soon  as  it  passed  the  lips  the  child  cried 
and  coughed.  None  of  the  acid  was  swallowed,  apparently,  but 
sufficient  was  aspirated  into  the  larynx  to  produce  intense  congestion  and 
sufficient  edema  to  require  immediate  operative  measures.  The  parts 
sloughed  extensively  and  the  child  died  in  two  weeks  from  pneumonia 
resulting  from  sepsis. 

Treatment. — No  case  of  corrosive  injury  to  the  mucous  membrane, 
sufficient  to  produce  congestion  and  edema  with  a  resulting  inspiratory 
obstruction  which  requires  operative  relief,  should  ever  be  intubated 
except  as  a  temporary  expedient,  since  the  presence  of  a  tube  will  in- 
variably cause  extensive  sloughing.  If  the  case  is  urgent,  tracheotomy 
is  the  only  justifiable  operation.  In  two  cases  due  to  irritating  gases 
(sulphur  dioxid  in  one  case  and  steam  inhalation  in  another)  the  treat- 
ment consisted  in  the  use  of  cold  applications  to  the  neck  by  means  of 
wet  compresses  at  a  temperature  of  60°F.     Both  cases  recovered. 

LARYNGEAL  OBSTRUCTION 

Laryngeal  obstruction  may  be  either  complete  or  partial,  causing 
entire  cessation  of,  or  greatly  impeded,  respiration.  As  the  calls  upon 
the  physician  for  aid  in  these  cases  are  attended  with  great  urgency, 
it  is  well  to  bear  in  mind  the  conditions  which  may  give  rise  to,  or  di- 
rectly cause,  laryngeal  obstruction.  These  are  referred  to  in  detail 
under  their  respective  headings.  In  order  of  frequency  they  occur  as 
follows : 

1.  Acute  Catarrhal  Laryngitis  (Catarrhal  Croup),  p.  287. 

2.  Laryngismus  Stridulus,  p.  487. 

3.  Retropharyngeal  Abscess,  p.  275. 

4.  Foreign  Bodies  in  the  Larynx  (see  below). 

5.  Traumatic  Laryngitis,  p.  291. 

6.  New-growths.  ' 

7.  Membranous  Laryngitis  (Laryngeal  Diphtheria),  p.  636. 
Acute   catarrhal   laryngitis,    membranous   laryngitis,  laryngismus 

stridulus,  and  retropharyngeal  abscess  are  by  far  the  most  frequent 
causes  of  laryngeal  obstruction  in  children.  In  children,  edema  is  a 
very  infrequent  cause  of  laryngeal  obstruction.  When  present,  it  is 
a  complication  or  sequel  of  other  pathologic  states;  for  example,  it 
may  result  from  an  inflammation  accompanying  a  low-placed  retro- 
pharyngeal abscess,  a  traumatic  laryngitis  after  the  inhalation  of  irri- 
tating gases,  or  from  the  aspiration  of  corrosive  fluids  or  powders. 
The  part  played  by  the  thymus  gland  in  causing  laryngismus  is  not 
at  all  clear — the  subject  has  been  discussed  on  page  487. 

Illustrative  Case. — A  patient  eighteen  months  of  age,  during  convalescence 
from  a  mastoid  operation,  developed  a  cellulitis  in  the  tissue  about  the  wound. 
The  inflammation  involved  the  entire  side  of  the  face,  the  lips,  and  mucous  mem- 
brane of  the  mouth,  and  eventually  extended  to  the  larynx,  producing  edema,  with 
most  urgent  symptoms  of  laryngeal  obstruction. 

FOREIGN  BODIES  IN  THE  LARYNX 

Foreign  bodies  are  usually  lodged  in  the  larynx  by  an  act  of  sudden 
inspiration  attended  by  a  quick  forward  movement  of  the  head,  as  in 


ADENOIDS  293 

coughing  or  laughing  with  a  foreign  body  in  the  mouth  or  between  the 
teeth.  The  patient  is  immediately  seized  with  a  violent  paroxysm  of 
coughing  and  suffocation,  the  severity  of  which  depends  upon  the  size 
and  shape  of  the  foreign  body. 

Treatment. — Inversion  of  the  patient  has  been  of  no  service  what- 
ever in  the  cases  seen  by  me.  The  first  procedure  is  to  introduce  into 
the  mouth  the  index-finger,  with  the  hope  that  a  portion  of  the  mass  may 
protrude  sufficiently  to  make  possible  its  removal.  Should  the  attempt 
fail,  a  laryngeal  forceps  should  be  brought  into  use,  its  introduction 
being  guided  and  guarded  by  the  index-finger.  When  this  is  not 
successful,  tracheotomy  should  be  performed  to  relieve  the  child  from 
immedite  danger  of  suffocation,  after  which  further  surgical  procedures 
may  be  considered. 

ADENOIDS 

The  recognition  of  adenoid  growths  as  a  cause  of  nasal  obstruction 
has  been  appreciated  only  during  the  past  thirty  years.  The  vege- 
tations were  first  described  by  Dr.  Wilhelm  Meyer,  of  Copenhagen,  in 
1868. 

Pathologically,  they  exist  as  overgrowths  of  the  lymphoid  tissue 
normally  present  in  the  nasopharynx.  When  the  lymphoid  elements 
alone  are  increased,  the  growths  are  soft  and  spongy,  but  when,  as  is 
frequently  the  case,  there  is  marked  development  of  fibrous  tissue, 
they  are  firm  and  resistant.  Increase  in  the  connective  tissue  is 
primarily  a  perivascular  process.  Ultimately  atrophy  of  the  lymphoid 
tissue  occurs,  resulting  in  contracture  of  the  adenoid  mass.  This 
change  has  been  commonly  attributed  only  to  late  childhood  and  early 
adult  life.  Such  changes,  however,  are  not  uncommon  in  the  very 
young.  The  spontaneous  abatement  of  symptoms  which  is  so  fre- 
quently observed  in  young  adults  is  more  probably  due  to  increase  in 
the  capacity  of  the  epipharynx  than  to  actual  diminution  in  the  size  of 
the  obstructing  mass. 

Etiology. — Adenoids  are  found  in  all  classes  of  children.  In  propor- 
tion to  the  population,  they  are  as  frequent  among  the  wealthy  and  well- 
to-do,  as  among  the  poorer  classes.  In  fact,  if  the  throats  of  all  chil- 
dren were  carefully  examined  with  the  finger,  adenoid  vegetations  in  the 
nasopharyngeal  vault  would  be  found  in  95  per  cent,  of  the  cases.  This, 
however,  does  not  mean  that  95  per  cent,  of  children  should  have  the 
adenoids  removed,  as  in  some  instances  the  growth  is  very  small  and 
fairly  innocent. 

The  fact  that  adenoids  are  so  generally  prevalent  among  all  classes 
and  conditions  of  children  points  to  a  common  causative  agent,  or 
group  of  agencies.  I  believe  that  the  wide  prevalence  of  the  growths  is 
due  to  the  following  conditions : 

First:  There  is  a  tendency  to  overgrowth  of  lymphoid  tissue  in  all 
children. 

Second :  The  location  of  the  normal  lymphoid  tissue  in  the  pharyn- 
geal vault,  subjects  this  tissue  to  the  irritation  of  dust  and  sudden 


294  THE    PRACTICE    OF    PEDIATRICS 

currents  of  cold  air,  resulting  in  the  pathologic  changes   described. 

Third:  The  first  and  second  conditions  prepare  the  parts  for  the 
action  of  the  third  factor — bacteria. 

A  curved  probe  tipped  with  sterilized  cotton  when  passed  into  the 
adenoid  tissue  of  any  child,  whether  the  amount  of  tissue  is  small  or 
large,  will  afford  a  culture  of  the  secretion,  in  which  may  be  found  the 
streptococcus,  staphylococcus,  pneumococcus,  influenza  bacillus,  and 
many  other  pathogenic  organisms.  The  local  congestion  caused  by 
the  presence  of  hordes  of  bacteria  further  increases  the  hypertrophy 
of  the  adenoid  mass. 

Heredity  is  of  no  immediate  consequence.  If  a  new  race  of  children 
could  be  born  free  from  adenoid  antecedents,  they  would  just  as  surely 
develop  the  growths. 

Age. — If  a  child  passes  the  fourth  year  without  adenoids,  he  will 
probably  not  acquire  them  later.  Children  are  born  with  adenoids. 
At  what  period  in  utero  they  develop  is  not  known.  I  have  seen  them 
at  birth  in  infants  with  cleft-palate.  Adenoids  were  present,  in  quite 
considerable  amount,  in  one  infant  who  was  one  month  premature. 
Signs  of  the  growths  do  not  ordinarily  develop  before  the  end  of  the 
first  year.  The  great  majority  of  cases  come  under  observation  be- 
tween the  eighteenth  month  and  the  fifth  year.  I  have  operated 
upon  four  children  nine  months  of  age,  because  in  each  instance  the 
parents  insisted  that  the  child  be  given  relief  from  a  growth  which 
completely  blocked  the  nasopharyngeal  vault.  The  extremes  as 
regards  age  in  cases  upon  which  I  have  operated  are  six  months  and 
fifteen  years.  While  we  do  not  see  many  cases  until  the  patients  are 
two  or  three  years  of  age  or  older,  I  am  convinced  that,  in  a  large  major- 
ity, the  process  begins  during  the  first  year. 

Symptoms. — Some  children  have  large,  roomy  nasopharyngeal 
vaults,  while  in  others,  on  account  of  the  high  palatal  arch  and  the 
prominence  of  the  bodies  of  the  vertebrse,  this  space  is  very  small. 
In  the  latter  cases  a  very  small  amount  of  adenoid  tissue  causes  marked 
obstruction.  The  character  and  amount  of  the  growth  likewise  de- 
termine the  degree  of  inspiratory  impairment  and  the  severity  of  the 
related  symptoms. 

Mouth-breathing. — In  all  cases  showing  a  considerable  growth, 
and  in  others  in  which  a  moderate  growth  exists  in  a  small  vault, 
mouth-breathing  occurs,  because  the  natural  respiratory  tract  is 
partially  blocked. 

Rhinitis. — A  more  or  less  persistent  rhinitis  is  also  present,  and  this 
is  intermittent — now  better,  now  worse.  It  is  usually  worse  during 
the  winter;  during  the  summer  in  some  cases  it  may  disappear,  only 
to  return  with  the  first  cold  weather.  In  other  cases,  with  con- 
siderable adenoid  growth,  the  nasal  discharge  never  ceases,  but  is  apt 
to  be  worse  during  the  winter  and  spring  months.  The  child  cannot 
blow  the  nose,  the  voice  and  speech  are  defective,  and  the  voice  has  a 
nasal  quality.  Certain  letter  sounds,  such  as  "m"  and  "n"  in  the 
words   "spring"  and   "bang"  are  pronounced  with  difficulty.     Be- 


ADENOIDS 


295 


cause  of  the  presence  of  the  mechanical  obstruction  in  the  natural  re- 
spiratory passage,  the  child  breathes  through  the  mouth,  not  only 
when  awake,  but  when  asleep,  and  consequently  snores,  and  is  noisy 
and  restless,  tossing  about  and  assuming  all  sorts  of  awkward  positions 
during  sleep. 

Adenoid  Face. — These  children  all  have  the  characteristic  adenoid 
face.  The  term,  mouth-breathing,  does  not  describe  the  condition  ap- 
parent in  a  pronounced  case  in  an  older  child.  The  masseters  become 
so  relaxed  that  a  habitual  drop  jaw  results.  The  nostrils  are  usually 
small;  the  nasolabial  folds  are  deepened. 


Fig.  28. — Adenoid  face. 

Adenoids  Without  Facial  Deformity. — In  a  child  with  a  roomy  vault, 
adenoids  in  small  or  medium-sized  masses  may  be  present  without  pro- 
ducing facial  deformity  or  obstructive  symptoms. 

Apart  from  the  characteristic  appearance  of  the  patients,  two 
symptoms  suggest  adenoids: 

First:  Persistent  rhinitis,  indicated  by  habitual  nasal  discharge, 
which  is  ascribed  to  a  chronic  cold. 

Second :  Cough,  habitual,  mild,  or  severe.  It  may  be  paroxysmal. 
I  have  repeatedly  known  this  symptom  to  be  confused  with  whooping- 
cough.  (See  p.  616.)  The  cough  is  always  worse  when  the  patient  is 
lying  down.  Many  of  these  cases  pass  unrecognized,  adenoids  being 
unsuspected  because  of  the  absence  of  obstructive  signs,  while  the  cough 
is  attributed  to  the  stomach,  dentition,  worms,  nervousness,  etc. 


296  THE    PRACTICE    OF    PEDIATRICS 

Diagnosis. — The  open  mouth  (see  Fig.  28),  the  snoring  at  night, 
the  stupid  expression,  the  disturbed  articulation,  the  persistent  nasal 
discharge,  the  deafness,  the  inability  to  blow  the  nose,  the  cough,  and 
the  chronicity  of  the  symptoms  all  combine  to  make  a  picture  afforded 
by  no  other  condition.  No  special  type  of  child  is  affected.  We  find 
adenoids  not  onl}^  in  the  delicate  and  ailing,  but  also  in  the  strong  and 
well.  Among  hundreds  of  cases,  I  have  seen  very  few  in  which  a  part 
in  the  production,  of  the  growths  could  be  attributed  to  lymphatism. 

Method  of  Examination. — In  children,  after  the  fifth  or  sixth  year, 
satisfactory  examination  by  means  of  mirrors  and  illumination  is  oc- 
casionally possible.  Occasionally  a  rhinologist  will  state  that  he  is 
able  to  make  all  necessary  examinations  in  much  younger  children,  by 
means  of  posterior  rhinoscopy.  I  have  never  seen  this  demonstrated 
and  do  not  expect  to. 

Although  such  procedure  is  disagreeable  to  the  patient,  I  prefer  the 
finger  examination  in  all  cases.  The  child  is  securely  held  by  an  at- 
tendant, with  the  arms  pinned  to 'the  sides.  A  mouth-gag  or  tongue- 
depressor  is  then  placed  between  the  teeth,  at  right  angles  to  the  jaw, 
and  held  in  position  by  the  left  hand  of  the  examiner,  thus  allowing 
the  right  finger  to  be  free  for  the  examination. 

Association  with  Enlarged  Tonsils. — In  the  very  young,  adenoids 
usually  exist  independent  of  enlargement  of  the  tonsils.  The  older  the 
child,  the  more  frequent  in  occurrence  is  the  involvement  of  the  tonsils. 
Enlarged  or  diseased  tonsils  without  adenoids  are  found  only  with  the 
greatest  rarity. 

Treatment. — Treatment  other  than  by  operation  is  highly  ridicu- 
lous. 

The  Operation  for  Temporary  Relief. — Early  infancy  is  no  contra- 
indication to  operation,  if  the  conditions  are  sufficiently  urgent.  For- 
tunately, the  necessity  for  a  radical  operation  in  those  under  one  year 
of  age  is  comparatively  rare.  These  little  patients,  however,  may  have 
obstructing  growths  sufficient  to  give  rise  to  mouth-breathing  and  dif- 
ficulty in  nursing,  and  also  to  a  very  annoying  and  persistent  nasal  dis- 
charge. At  this  age  the  adenoid  tissue  is  usually  very  soft  and  friable. 
In  several  instances  I  have  temporarily  relieved  such  an  infant  by 
crushing  the  growth  with  the  clean  index-finger  tip  wrapped  in  a  couple  of 
layers  of  sterile  gauze.  The  finger-nail  should  be  cut  very  short  and 
the  whole  hand  thoroughly  scrubbed  and  disinfected.  The  child 
should  be  wrapped  and  pinned  in  a  large  towel,  with  the  arms  confined 
to  the  sides,  and  then  placed  on  the  back  on  a  bed  or  table.  A  clean 
towel  for  wiping  away  the  blood  should  be  placed  under  the  head.  The 
mother  and  nurse  should  be  advised  that  slight  bleeding  is  expected. 
When  the  child  is  in  position,  the  physician  may  hold  the  mouth  open 
with  a  spoon  or  tongue-depressor,  and  then  pass  the  index-finger  of  the 
right  hand  backward  into  the  vault  and  easily  break  up  the  soft,  spongy 
growth  which  may  be  present.  The  adenoids  are  by  no  means  re- 
moved by  this  method,  but  their  continuity  is  destroyed  and  portions  of 
the  growth  doubtless  slough  off,  thus  affording  temporary  relief.     The 


HYPERTROPHIED   AND   PERMANENTLY   DISEASED   TONSILS        297 

child  will  be  able  to  nurse  without  inconvenience,  and  the  nasal 
discharge  will  stop.  In  six  months  or  a  year,  however,  the  symptoms 
will  return  and  the  radical  operation  should  then  be  deferred  no  longer. 
The  combined  operation  for  the  removal  of  both  tonsils  and  adenoids 
which  is  the  usual  practice,  will  later  be  described.     (See  p.  298.) 

HYPERTROPHIED  AND  PERMANENTLY  DISEASED  TONSILS 

Chronic  enlargement  of  the  tonsils  is  usually  the  result  of  repeated 
attacks  of  tonsillitis.  Notwithstanding  this  fact,  I  have  repeatedly 
seen  enlarged  tonsils  which  had  never  been  inflamed.  A  tonsil  is 
considered  abnormally  large  when  it  extends  beyond  the  pillars  of  the 
fauces.  Enlarged  tonsils  not  only  produce  mouth-breathing,  faulty 
articulation,  and  catarrh  of  the  Eustachian  tube,  but  are  doubtless  a 
factor  in  the  etiology  of  adenoids. 

Without  being  enlarged,  a  tonsil  may  still  exist  as  a  menace  to  the 
owner.  The  very  small  tonsil  which  is  badly  diseased,  and  the  small, 
deeply  buried  tonsil,  largely  covered  by  the  pillars,  are  sources  of  great 
danger.  In  the  crypts — whether  the  organ  is  large  or  small — are  har- 
bored myriads  of  bacteria  capable  of  producing  repeated  attacks  of 
acute  infla.mmation.  The  streptococcus,  staphylococcus,  colon  bacillus, 
pneumococcus,  the  tubercle  bacillus,  and  the  Klebs-Loffler  bacillus 
all  abound.  The  crypts  of  diseased  tonsils  unquestionably  may  supply 
the  infective  agent  in  pericarditis,  endocarditis,  nephritis,  anemia  and 
the  various  toxemias  classified  under  the  broad  term  of  rheumatism. 
Adenitis,  both  tuberculous  and  simple,  is  very  rare  in  children  who  do 
not  have  foci  of  disease  in  their  throats. 

The  Necessity  for  Operative  Interference  in  Cases  of  Diseased  Ton- 
sils and  Adenoids. — The  simple  indication  to  relieve  mechanical  ob- 
struction is  by  no  means  the  sole  criterion  in  advising  operative  measures. 
Diseased  tonsils  are  responsible  in  no  small  degree  for  many  of  the  com- 
plications attending  other  diseases.  In  influenza,  diphtheria,  scarlet 
fever,  and  measles  the  throat  always  shows  active  participation.  A 
child  free  from  adenoids  and  diseased  tonsils  presents  greatly  increased 
resistance  to  all  these  diseases;  and  complications  in  such  children,  par- 
ticularly as  relates  to  the  lymphatic  glands  and  ears,  are  most  unusual. 
During  even  a  common  cold,  however,  a  mass  of  adenoids  in  the  vault 
serves  as  a  very  efficient  means  of  conveying  infection  to  the  middle  ear. 
A  small  percentage  of  middle-ear  cases  develop  mastoid  disease,  and 
in  a  still  smaller  percentage  sinus  thrombosis,  with  or  without  jugu- 
lar involvement.  In  advising  parents,  the  physician  should  clearly 
portray  the  culture-field  which  the  child  may  be  carrying  in  the  upper 
respiratory  tract. 

Operation  for  Permanent  Relief. — I  regard  this  as  an  operation 
with  which  the  general  practitioner  should  familiarize  himself,  and 
for  this  reason  a  description  of  the  operative  procedure  is  included  in 
this  book.  The  operation  is  not  performed  alike  by  all.  Some  prefer 
the  sitting  position- without  an  anesthetic;  others  employ  anesthesia 


298  THE    PRACTICE    OF    PEDIATRICS 

and  raise  the  patient  to  a  sitting  position  at  the  time  of  the  operation. 
It  is  my  opinion  that  an  anesthetic  should  be  used  in  every  case  unless 
contraindicated  by  some  such  condition  as  lymphatism  or  cardiac  or 
kidney  disease,  which  might  make  the  anesthesia  dangerous.  In 
operations  upon  children  over  two  years  of  age  my  preference  is  to  give 
nitrous  oxid  gas  to  produce  unconsciousness,  and  then  to  substitute 
ether.  This  procedure  is  far  more  agreeable  to  the  patient  than  the 
use  of  ether  frorn  the  beginning.  Primary  anesthesia  is  all  that  is  re- 
quired. In  dealing  with  the  very  young,  for  whom  gas  is  not  per- 
missible on  account  of  producing  cyanosis,  ether  alone  may  be  used. 
Chloroform  I  have  learned  to  regard  with  much  distrust.  A  boy  three 
years  of  age  upon  whom  I  was  to  operate  for  adenoids  came  so  near 
dying  under  chloroform  anesthesia  that  resuscitation  was  almost 
despaired  of.  With  another  child  I  had  a  similar  experience.  I  have 
never  witnessed  any  unpleasant  effects  from  ether  during  these 
operations. 

If  the  operation  is  to  be  performed  without  an  anesthetic,  the  up- 
right position  is  best.  The  child's  arms  should  be  bound  to  the  side 
with  a  large  towel  and  fastened  with  safety-pins.  He  should  be  held 
on  the  lap  on  the  right  side  of  an  attendant,  who,  by  crossing  his  legs, 
confines  between  them  the  legs  of  the  patient.  The  attendant's  right 
arm  encircles  the  child,  while  the  left  controls  the  head,  which  rests 
against  the  attendant 's  right  shoulder.  A  basin  should  be  within  reach, 
as  the  bleeding  is  sudden  and  profuse. 

The  Radical  Removal  of  the  Tonsils  and  Adenoids. — Until  fifteen 
years  ago  my  method  was  to  remove  as  much  of  the  tonsil  as  pos- 
sible by  firm  pressure  with  the  tonsillotome  and  counterpressure 
by  an  assistant,  but  without  any  attempt  at  dissection  or  complete 
removal  of  the  tonsil.  This  resulted  in  the  removal  of  perhaps  two- 
thirds  or  seven-eighths  of  the  tonsil,  leaving  the  capsule  and  some  ton- 
sillar tissue.  The  great  majority  of  my  cases  so  operated  upon  were 
benefited  permanently.  In  others  the  benefit  was  very  temporary, 
the  tonsil  soon  assuming  the  former  size,  the  new-growth  showing 
connective-tissue  changes  and  adhesions  to  the  pillars,  which  made  the 
condition  worse  than  it  was  before  the  operation.  Even  in  the  cases 
in  which  a  regrowth  of  the  tonsil  did  not  occur  the  same  tendency  to 
tonsillitis  persisted,  and  the  tonsil  remained  a  portal  of  entry  for 
bacteria.  Furthermore,  second  and  third  operations  have  been  nec- 
essary under  this  procedure.  I  have  performed  the  second  operation 
after  various  other  operators,  as  well  as  in  my  own  cases. 

Forty-eight  hours  before  the  operation  10  grains  of  calcium  lactate 
is  given  three  times  daily,  the  last  10  grains  being  given  after  8  ounces 
of  chicken  broth,  on  the  morning  of  the  operation.  I  am  convinced 
that  the  calcium  lactate  lessens  the  amount  of  hemorrhage. 

The  method  of  procedure  is  as  follows,  after  the  method  of  Dr. 
F.  S.  Mathews :  Ether  or  gas-ether  anesthesia  is  used.  The  anesthetic 
is  given  to  the  point  of  abolishment  of  the  corneal  reflexes.  The  child 
is  gagged  sufficiently  to  allow  the  entrance  of  the  index-finger,  which 


HTPERTKOPHIED    AND    PERMANENTLY   DISEASED    TONSILS         299 

must  have  free  play,  our  object  being  to  perform  such  a  tonsillectomy 
as  to  strip  the  tonsil  from  its  bed.  For  the  right  tonsil  I  pass  my 
right  index-finger  into  the  mouth,  and  with  moderate  pressure  and 
finger-point  dissection,  pass  the  finger  into  the  superior  fossa  at  the 
junction  of  the  anterior  and  posterior  pillar,  I  thus  enter  the  finger 
above  the  tonsil,  work  down  behind  the  capsule,  pull  the  tonsil  down- 
ward, and  with  the  pressure  exerted  first  anteriorly  and  then  pos- 
teriorly, separate  the  structure  from  its  attachments  until  it  hangs 
by  a  pedicle  formed  by  the  mucosa  and  blood-vessels.  Over  this  as 
small  a  tonsillotome  as  will  engage  the  tonsil  is  slipped.  The  anes- 
thetist makes  firm  pressure  from  without,  and  the  operator  with  firm 
pressure  on  the  tonsillotome  within  cuts  the  pedicle.  No  tonsil  tissue 
is  cut.  Without  the  interference  of  firm  connective  tissue,  the  blood- 
vessels in  the  pedicle  readily  contract. 

Mathews  places  the  gag  on  the  side  opposite  the  immediate  site  of 
operation.  I  do  not  find  this  necessary  except  in  very  young  children 
or  those  with  small  mouths. 


Fig.  29 


Figs.  29  and  30. — Adenoid  curets. 

For  the  removal  of  the  left  tonsil  a  similar  procedure  is  carried  out, 
excepting  that  the  left  finger  is  used.  I  have  had  but  little  difficulty 
in  removing  the  entire  tonsil  by  this  method. 

The  removal  of  the  adenoids  is  very  simple  and  requires  but  a  few 
seconds.  I  use  a  modified  Gottstein  curet,  which  is  built  at  an  angle 
of  about  45  degrees.  (See  Figs.  29  and  30).  This  allows  greater  play 
of  the  cutting  blade  in  the  vault.  This  curet  is  very  sharp.  Two  or 
three  sweeps  suffice  to  remove  all  the  adenoid  tissue,  hard  and  soft. 

When  the  patient  is  removed  from  the  table,  he  has  recovered  suf- 
ficiently from  the  anesthesia  to  cry  vigorously.  He  is  given  nothing 
but  broths  and  gruels  for  the  day.  Six  to  eight  hours  after  the 
operation  an  enema  is  given.  The  following  day  he  sits  up  in  bed 
and  plays.  The  next  day  he  is  up  and  about,  and  on  the  succeeding 
day,  out-of-doors.  Neither  ice  cream  nor  milk  is  given  on  the  day  of 
the  operation.  I  have  experienced  no  little  trouble  with  children  who 
have  been  given  milk  or  ice  cream  within  a  few  hours  after  the  opera- 
tion. The  indigestion  and  high  temperature  which  are  very  apt  to 
result  alarm  the  family,  who  are  inclined  to  attribute  the  manifestations 
to  infection  or  something  else  of  a  very  dangerous  nature. 

It  is  claimed  by  the  opponents  of  this  finger  method  that  complica- 


300  THE    PRACTICE    OF    PEDIATRICS 

tions  follow  the  operation,  and  that  end  results  occur  which  are  dis- 
tinctly harmful.  I  have  had  one  case  of  postoperative  adenitis  which 
responded  promptly  to  local  treatment  with  cold  applications.  The 
child  had  a  temperature  of  102°F.  to  104°F  for  three  days.  I  have  also 
had  one  case  in  which  adhesions  were  formed  by  the  pillars  growing 
together.  I  have  had  no  excessive  hemorrhage  at  the  time  and  no 
postoperative  hemorrhage.  This,  I  believe,  is  due  to  the  fact,  as  men- 
tioned before,  that  the  tonsil  tissue  is  not  cut  and  the  vessels  in  the 
pedicle  readily  contract. 

Rarely  have  I  found  it  necessary  to  use  any  other  instrument  than 
the  jBnger.  In  three  or  four  instances  a  pillar  separator  and  blunt 
curved  scissors  have  been  necessary.  The  only  instruments  actually 
required  have  been  the  gag,  the  tonsillotome,  and  an  adenoid  curet. 

Conclusions. — The  finger-enucleation  method  has  the  following 
advantages : 

Rapidity. — The  child  is  kept  under  the  anesthetic  but  a  very  short 
time. 

Completeness. — The  entire  tonsil  is  removed  with  Httleor  no  cutting. 

Absence  of  hemorrhage,  for  reasons  already  given. 

Short  convalesence. 

Adhesions. — From  six  weeks  to  three  months  after  the  operation 
"the  nasopharyngeal  vault  should  be  examined  for  adhesions.  The 
adhesions  are  usually  attached  anteriorly  to  the  posterior  surface  of 
the  inferior  turbinates,  oftentimes  extending  in  a  fan-shaped  form 
to  the  posterior  and  lateral  wall.  My  attention  was  first  directed  to 
the  presence  of  these  adhesions  by  mothers  who  brought  their  children 
for  treatment  stating  that  the  adenoids  had  been  removed  and  that 
the  child  was  relieved  for  a  few  months,  after  which  the  obstruction 
became  as  marked  as  before.  The  operator  was  naturally  blamed  for 
not  completely  removing  the  adenoid  tissue. 

Examination  of  the  vaults  in  these  cases  disclosed  the  adhesions. 
These  are  usually  readily  removed  with  the  finger.  I  have  seen  three 
cases,  however,  in  which,  on  account  of  the  firmness  of  the  adhesions, 
this  could  not  be  done.  One  patient  was  recently  operated  upon  by  a 
New  York  laryngologist  for  relief  of  the  condition.  Besides  limiting 
the  normal  breathing  space  these  adhesions  may  cause  a  very  teasing 
and  troublesome  cough. 

Illustrative  Case. — A  girl  of  nine  years  came  to  me  because  of  a  persistent  cough, 
which  had  continued  during  the  winter  and  which  could  not  be  relieved.  She  had' 
been  operated  upon  for  adenoids  four  years  before.  I  found  fairly  firm  adhesions, 
which  I  reduced  with  the  finger.  The  cough  stopped  at  once.  The  mother  then 
brought  to  me  two  other  children  who  had  shown  unsatisfactory  results  from 
operations,  both  showing  adhesions. 

By  many  operators  the  existence  of  these  adhesions  is  denied.  I 
have  found  them  after  operations  performed  by  men  who  said  they 
did  not  know  of  them.  Every  physician  will  find  them  in  many  of  his 
own  patients  if  he  will  introduce  his  finger  into  the  vault  and  search. 

Benefits  of  the  Operation  for  Removal  of  the  Tonsils  and  Ade- 
noids.— The  usual  advantages  claimed,  those  relating  to  mouth-breath- 


POLLINOSIS,    POLLEN    DISEASE,    HAY    FEVER  301 

ing,  facial  deformities,  etc.,  are  sufficiently  well  known  to  be  omitted. 
I  will  call  attention,  however,  to  certain  benefits  that  are  perhaps  not 
generally  appreciated. 

In  Delicate  Children. — In  my  office  work  I  have  occasion  to  treat 
every  year  a  large  number  of  children  who  come  because  of  defective 
growth,  who  are  suffering  from  secondary  anemia,  or  who  are  otherwise 
delicate.  I  have  observed  remarkable  improvement  in  these  children 
following  the  removal  of  diseased  tonsils  and  adenoids. 

The  Acute  Injections. — In  grippe,  scarlet  fever,  measles,  diphtheria 
and  other  acute  infections,  a  considerable  source  of  danger  lies  in  the 
associated  pyogenic  infections  of  the  throat  and  nasopharynx,  involving 
secondarily  the  ears  and  the  adjacent  structures,  the  glands,  and 
through  the  blood  stream  to  the  kidneys  and  the  heart.  The  presence 
of  diseased  tonsils  and  adenoids  supplies  an  ideal  culture  field  for 
pyogenic  bacteria  and  greatly  enhances  the  child's  chances  for 
dangerous  complications.  For  example,  it  is  rare  to  find  an  otitis 
media  in  the  absence  of  adenoids. 

Adenitis. — Adenitis,  in  any  common  form,  is  a  very  unusual  occur- 
rence in  a  child  who  has  had  the  adenoids  and  tonsils  properly 
removed. 

Notwithstanding  the  large  number  of  cases  operated  upon,  I  have 
yet  to  hear  a  regret  expressed  by  the  parents  because  the  operation  was 
performed.  I  have  had  occasion  repeatedly  to  regret  that  a  complete 
enucleation  was  not  performed  in  my  earlier  cases. 

POLLINOSIS,  POLLEN  DISEASE,  HAY  FEVER 

Hay  fever  in  children  is  by  no  means  a  rare  disease.  My  youngest 
patient  was  three  years  of  age.  The  disease  is  due  to  the  influence  of 
plant  pollen  on  the  mucous  membrane  of  the  nose  and  throat  and 
represents  a  pollen  protein  anaphylaxis.  A  hay  fever  subject  may  be 
sensitized  to  one  or  half  a  dozen  pollens.  Individuals  who  react 
to  horse  serum  or  the  odor  of  the  horse  or  cat  are  very  liable  to  be 
found  sensitized  to  one  or  more  plant  pollens. 

The  pollens  of  golden  rod  and  rag  weed  are  perhaps  the  pollens 
most  frequently  causing  hay  fever.  Heredity  appears  to  play  an  im- 
portant part  in  the  etiology.  Oppenheimer  and  Gottlieb*  report  that 
in  90  per  cent,  of  their  cases  members  of  the  family  of  the  patients 
suffered  with  ailments  showing  manifestations  of  anaphylaxis. 

Diagnosis. — The  disease  may  manifest  itself  any  time  during 
the  period  of  the  flowering  of  plants.  The  first  sign  is  usually  that  of 
profuse  lacrimation  with  itching  and  burning  of  the  eyes.  Sneezing 
and  a  profuse  watery  nasal  discharge  are  rarely  absent.  In  many 
cases  asthmatic  seizures  develop. 

The  seizures  continue  in  a  given  case  while  the  individual  is  sub- 
jected to  the  action  of  the  pollen  to  which  he  is  sensitized.  As  men- 
tioned above  many  hay  fever  subjects  are  sensitized  to  various  pollens 
*  Medical  Record,  March  18,  1916. 


302  THE    PRACTICE    OF    PEDIATRICS 

and  the  disease  may  continue  during  the  entire  flowering  period  of  plants 
from  May  until  October. 

The  Scratch  Skin  Test. — Individuals  who  are  sensitized  to  a 
pollen  will  show  a  cutaneous  reaction  to  the  pollen  protein. 

Technique  of  the  Test. — The  test  is  identical  with  that  employed 
for  testing  for  sensitization  to  horse  serum,  lactalbumen,  or  egg  white. 

A  small  scratch  is  made  on  the  skin,  not  sufficient  to  produce 
bleeding.  Into  this  abrasion  is  rubbed  the  pollen  of  the  plant  to  be 
tested.  A  similar  scratch  is  made  for  control.  If  the  individual  is 
sensitized  to  the  pollen  used  an  area  of  redness  and  infiltration  will 
appear  at  the  site  of  the  abrasion. 

This  constitutes  the  reaction  which  will  vary  in  degree  from  a 
distinct  definable  redness,  Positive  +,  to  the  development  of  an  ur- 
ticarial wheal,  Postive  +  +  +  + ,  the  varying  degrees  of  reactions  being 
indicated  by  the  sign  + , 

In  the  absence  of  reaction  the  test  is  recorded  as  negative. 

Cook  and  Vanderveer  mention  25  plants  which  they  have  personally 
proven  had  caused  hay  fever. 

Treatment. — Those  who  desire  to  treat  hay  fever  in  the  use  of 
pollen  preparations  are  advised  to  consult  the  publications  of  Cook 
and  Vanderveer*  and  of  Oppenheim  and  Gottlieb,  f  ' 

The  Lungs 
examination  of  lungs 

Four  methods  are  commonly  employed  in  lung  examination: 
(1)  Inspection.     (2)  Palpation.     (3)  Percussion.     (4)  Auscultation. 

Inspection. — Inspection  of  infants  and  young  children  is  of  value 
in  determining  the  existence  and  nature  of  any  deformity,  as  well  as  the 
rapidity  and  character  of  the  respiration.  The  frequency  of  respiration 
varies  considerably  in  children.  The  younger  the  child,  the  more  rapid 
the  respiration.     The  variations  are  about  as  follows: 

Under  one  year  of  age 30  to  40 

One  to  three  years  of  age 24  to  30 

Three  to  ten  years  of  age 20  to  24 

The  most  common  deformity  is  the  rachitic  chest  or  so-called  pigeon- 
breast.  In  association  with  the  rachitic  chest,  as  one  of  the  results  of 
the  rachitis,  is  found  the  funnel  chest,  which  is  characterized  by  marked 
depression  of  the  sternum. 

The  Depressed  or  Contracted  Chest. — This  condition  is  a  result  of 

pneumonia  with  pleuritic  exudation  and  subsequent  adhesions  between 

the  lung  and  the  chest- wall.     Dilatation  of  the  lung  is  interfered  with; 

the  balance  between  the  intrathoracic  and  extrathoracic  air  pressure 

is  not  maintained,  and  deformity  is  the  outcome.     Inspiration  is  marked 

by  a  lack  of  motion  on  the  part  of  the  diseased  side  as  compared  with 

the  normal  side. 

*  Journal  Immunology,  vol.  i,  no.  iii. 
t  N.  Y.  Medical  Journal,  no.  vi,  101. 


EXAMINATION    OF    LUNGS  303 

The  Distended  Chest. — When  there  is  effusion  into  the  pleural 
cavity,  and,  rarely,  when  there  is  pneumothorax,  one  side  of  the  chest 
may  be  much  larger  than  the  other.  In  thin  subjects  the  marking  of 
the  ribs  is  much  less  pronounced  than  normal,  the  sunken  interspace 
being  obliterated  by  the  pressure  from  within.  In  the  distended 
chest  also  there  will  be  observed  a  marked  absence  of  respiratory  move- 
ment. I  have  seen  a  great  many  cases,  however,  of  pleuritic  effusion 
in  which  such  bulging  was  not  present. 

Asthmatic  or  Fixed  Chest.' — Chests  of  this  type  are  quite  common 
in  children  and  are  so  characteristic  that  by  watching  the  respiration 
one  may  readily  make  a  correct  diagnosis  of  the  existing  condition. 
In  children  normal  breathing  is  of  the  costal  type;  that  is,  there  is  an 
outward  movement  of  the  ribs  in  inspiration  and  a  downward  and 
inward  movement  of  the  ribs  in  expiration.  In  the  emphysematous 
and  those  undergoing  asthmatic  seizures,  both  sides  of  the  chest  be- 
come inactive  and  the  respiration  is  largely  diaphragmatic. 

Defective  Expansion. — In  pneumonia  and  in  pleurisy  there  is  de- 
layed and  incomplete  expansion  of  the  diseased  side.  In  pneumonia, 
also,  there  is  unusual  rapidity  of  respiration;  and  in  acute  pleurisy, 
characteristic,  guarded,  interrupted  inspiration.  In  atelectasis  the 
inspiration  is  very  feeble  and  little  or  no  expansion.  In  empyema 
and  pneumothorax  there  is  little  or  no  expansion  over  the  affected 
area. 

Palpation. — Palpation  of  infants  and  young  children  is  of  little 
value.  Fremitus  serves  only  to  corroborate  what  may  be  learned  by 
percussion  and  auscultation,  and  is  not  to  be  relied  upon.  The  absence 
of  fremitus  in  a  thin  or  average  built  child  usually  means  the  presence 
of  fluid  in  the  pleural  cavity,  but,  in  a  child  with  a  thick  layer  of 
adipose,  the  sign  is  of  little  or  no  value.  The  presence  of  marked 
fremitus  may  mean  consolidation  of  the  lung.  The  absence  of  fremitus 
is  no  guarantee  that  there  is  no  consolidation.. 

Percussion.- — The  value  of  percussion  depends  upon  the  normal 
resonance  of  the  chest  when  tapped  with  the  finger  or  other  instrument. 
What  is  known  as  normal  resonance  is  the  sound  produced  by  percussion 
over  an  air-filled  lung.  The  usefulness  of  percussion  in  physical  diag- 
nosis depends  upon  the  nature  or  quality  of  the  note  and  the  sense  of 
resistance  imparted  by  the  chest  to  the  percussed  finger.  When  pos- 
sible, percussion  should  be  practised  with  the  patient  in  a  standing  or 
sitting  posture.  The  child  should  be  quiet,  if  possible,  as  crying  not 
only  disturbs  the  listener,  but  changes  the  quality  of  the  note  as  a  result 
of  the  air  taken  into  the  chest  and  the  tension  on  the  chest  muscles. 
Light  percussion  with  the  finger  is  preferred  to  that  obtained  by  plexi- 
meter.  The  chief  value  of  percussion  in  pulmonary  diagnosis  is  in  de- 
termining presence  of  fluid  in  the  chest. 

The  terms  employed  for  expressing  the  findings  in  a  given  case  are 
normal  resonance,  tympanitic  resonance,  dulness,  tympanitic  duhiess, 
and  flatness.  The  possibilities  of  variations  in  the  resonance  within 
the  normal  are  considerable.     The  position  of  the  patient,  the  age  of  the 


304  THE    PRACTICE    OF    PEDIATRICS 

patient,  the  condition  of  the  patient,  whether  thin  or  fat,  whether 
quiet  or  crying,  are  all  factors  which  may  cause  the  percussion-note  to 
vary.  The  student  should  familiarize  himself  with  the  normal  by 
percussing  the  chests  of  many  normal  children  of  different  ages. 

Tyni'panitic  resonance  is  obtained  over  a  hollow  body,  as  over  the 
stomach,  over  a  distended  colon,  or  a  pneumothorax. 

Dulness  is  characterized  by  short,  high-pitched  sounds,  caused  by  a 
solid  body  or  fluid  within  the  chest  cavity,  which  interferes  with  the 
production  of  the  normal  resonant  note. 

Flatness  is  the  extreme  degree  of  dulness,  and  is  best  demonstrated 
by  percussing  a  chest  filled  with  fluid.  An  important  feature  in  deter- 
mining dulness  and  flatness  is  the  sense  of  resistance  offered  the  percussed 
finger  by  the  chest-wall.  In  the  presence  of  contained  fluid  the  elas- 
ticity and  vibration  of  the  chest-wall  are  greatly  diminished  and  read- 
ily appreciated  by  the  finger  percussed. 

Auscultation. — Auscultation  consists  in  examination  of  the  lung  by 
the  ear  placed  directly  against  the  chest,  or  assisted  indirectly  by  a 
stethoscope  (p.  309).  The  use  of  the  stethoscope  in  infants  and  young 
children  is  almost  a  necessity.  On  account  of  the  smallness  of  the  chest 
and  the  comparatively  large  surface  of  the  field  covered  by  the  ear  during 
direct  auscultation,  a  larger  area  of  sound  conduction  is  covered  than 
is  desirable  for  purposes  of  accurate  diagnosis.  The  small  stethoscope 
bell  is  best,  for  the  reason  that  when  applied  to  the  chests  of  emaciated 
infants,  it  will  fit  the  surface  better  than  a  large  bell.  If  the  bell  does 
not  accurately  fit  the  chest,  extraneous  sounds  render  examination  im- 
possible. For  accurate  work  with  infants  the  unaided  ear — so-called 
immediate  auscultation — is  out  of  the  question.  With  older  children, 
after  the  third  or  fourth  year,  the  ear  alone  may  be  employed  if  the  phy- 
sician is  unable  to  accustom  himself  to  a  stethoscope.  The  physician 
must  accustom  himself  to  correct  auscultation  with  the  child  crying. 
This,  of  course,  means  forced  breathing  and  a  great  deal  of  extraneous 
noise.  To  one  who  is  accustomed  to  lung  examination  of  young  infants 
it  matters  little  whether  or  not  the  child  cries;  in  fact,  in  many  instances 
crying  is  of  distinct  advantage,  because  it  brings  out  the  respiratory 
quality  of  all  portions  of  the  lung.  In  older  children  forced  breathing 
is  necessary  to  transmit  the  sounds  we  require  for  diagnosis. 

In  auscultation  all  the  diagnostician 's  attention  is  required  for  the 
work  in  hand.  Concentration  of  the  mind  is  most  necessary.  For 
years  I  have  taught  students  to  close  their  eyes  during  auscultation, 
for  the  purpose  of  removing  all  visual  objects.  All  sounds  appear 
louder  in  the  darkness  or  when  the  eyes  are  closed.  The  position  of  the 
examiner  is  important.  He  should  sit  erect  or  lean  slightly  forward, 
but  never  incline  his  body  more  than  45  degrees.  When  the  examiner 
leans  too  far,  the  circulatory  changes  in  his  ears  make  his  work  un- 
satisfactory and  uncertain.  In  auscultation  it  is  the  object  of  the 
student  to  famiharize  himself  with  the  sound  produced  in  the  lung 
and  transmitted  to  the  chest- wall  in  the  act  of  normal  and  forced  breath- 
ing. The  sounds  thus  produced  are  known  as  those  of  vesicular 
breathing. 


EXAMINATION    OF    LUNGS  305 

Vesicular  breathing  has  a  range  of  variations  within  the  normal. 
As  in  the  matter  of  the  study  of  percussion  sounds,  repeated  examina- 
tions of  the  chest  of  normal  children  of  various  ages  and  conditions 
are  absolutely  required  before  the  nature  of  normal  breathing  and  its 
possible  variations  will  be  appreciated.  Various  terms  have  been  used 
in  a  comparative  sense  to  describe  vesicular  breathing,  such  as  "rust- 
ling," "blowing,"  "swishing,"  "purring,"  etc.;  these  are  all  mislead- 
ing and  useless  because  there  is  no  other  sound  resembling  the  sound 
of  vesicular  breathing  which  deserves  mention  in  comparison.  Differ- 
ent investigators  have  attempted,  by  means  of  various  devices,  to 


yr^ 


Fig.  31. — Vesicular  breath-     Fig.  32. — Distant  vesicular     Fig.  33. — Exaggerated 
ing.  breathing.  vesicular  breathing. 

produce  the  sounds  resembling  the  respiratory  murmur  in  health  and 
its  changes  in  disease,  without  success. 

The  respiratory  cycle  includes  the  taking  of  air  into  the  chest — 
inspiration;  and  the  forcing  of  the  air  out  of  the  chest — expiration. 
The  duration  of  inspiration  in  comparison  to  expiration  is  in  the  ratio 
of  five  to  three.  The  inspiratory  sound  is  not  only  longer,  but  harsher 
in  quality  than  that  of  expiration.  The  respiratory  characteristics 
are  diagrammatically  described  by  Cabot,  in  his  excellent  work  on 


Fig.  34. — Bronchial  breath-     Fig.  35. — Distant  bronchial     Fig.     36. — Very    loud 
ing  of  moderate  intensity.  breathing.  bronchial  breathing. 

physical  diagnosis.  Cabot's  diagrams  are  here  used,  but  modified  to 
correspond  to  the  respiratory  peculiarities  of  children. 

Inspiration  is  represented  by  the  upward  stroke  and  expiration  by 
the  downward  stroke.  The  length  of  the  upstroke,  as  compared  with 
that  of  the  downstroke,  corresponds  to  the  length  of  inspiration  as  com- 
pared with  that  of  expiration.  The  thickness  of  the  upstroke  as  com- 
pared with  that  of  the  downstroke  represents  the  intensity  of  inspira- 
tion as  compared  with  that  of  expiration.  The  pitch  of  inspiration  as 
compared  with  that  of  expiration  is  represented  by  the  sharpness  of  the 
angle  which  the  upstroke  makes  with  the  perpendicular. 

In  the  foregoing,  an  attempt  has  been  made  to  describe  the  various 
20 


306  THE    PRACTICE    OF    PEDIATRICS 

phases  of  normal  respiration.  That  the  two  sides  of  the  chest  may  show 
considerable  variation  within  the  normal,  due  to  changes  in  the  posi- 
tion of  the  body,  the  age  of  the  patient,  and  whether  he  is  at  rest  or 
active,  as  in  crying,  must  be  appreciated  and  learned  only  by  repeated 
studies  of  the  normal.  Only  when  the  student  has  so  practised  upon 
and  studied  the  normal  chest  is  he  ready  to  take  up  the  study  of  the 
signs  of  disease. , 

Exaggerated  breathing  occurs  when  a  sound  lung  or  portion  of  a 
sound  lung  is  called  upon  to  do  an  extra  amount  of  work.  This  type 
of  breathing  is  simply  compensatory,  and  occurs  when  a  considerable 
portion  of  lung  structure  is  incapacitated  by  consolidation,  as  in  pneu- 
monia, or  by  pressure,  as  in  the  event  of  effusion  into  the  pleural  sac. 

Diminished  or  weakened  breathing  exists  when  both  inspiration  and 
expiration  are  feebler  than  the  normal. 

Diminished  breathing  may  be  due  to  fluid  in  the  pleural  cavity,  to 
pleuritic  plastic  exudation  covering  the  lung  like  a  blanket,  to  partial 
infiltration  of  the  air-cells,  to  pneumothorax,  to  bronchitis,  because  the 
air  is  impeded  in  its  passage  to  the  air-cells,  and  to  acute  pleurisy  which 
gives  rise  to  much  pain  and  causes  a  much  shorter  excursion  of  the  chest- 
walls  than  normal.  In  all  these  conditions  inspiration  is  less  deep  than 
normal,  and  diminished  respiratory  sounds  are  the  result.  In  laryngeal 
spasm  and  in  diphtheric  laryngitis  the  respiratory  murmur  may  like- 
wise be  greatly  weakened  because  of  the  failure  of  sufficient  air  to  pass 
the  obstruction. 

Bronchial  breathing  is  symbolically  represented  and  described  by 
Cabot  as  follows: 

The  increased  length  of  the  downstroke  corresponds  to  the  increased 
duration  of  expiration,  the  greater  thickness  of  both  lines  corresponds 
to  the  greater  intensity  of  both  sounds,  expiratory  and  inspiratory, 
while  the  sharp  pitch  of  the  gable  on  both  sides  of  the  perpendicular 
corresponds  to  the  high  pitch  of  both  sounds.  Expiration,  it  will  be 
noticed,  slightly  exceeds  inspiration,  both  in  intensity  and  in  pitch, 
but  considerably  exceeds  it  in  duration.  As  compared  with  those  of 
vesicular  breathing,  almost  all  the  relations  are  reversed. 

Bronchial  breathing  is  found  in  conditions  in  which  there  is  com- 
plete infiltration  of  the  alveolar  air-cells,  leaving  only  the  bronchi 
open  to  the  inspired  air.  The  vesicular  element  in  the  breathing  is, 
therefore,  wanting,  and  the  sound  produced  by  the  passage  of  air 
through  the  tubes  is  alone  conveyed  to  the  ear;  and  the  more  readily 
because  of  the  solidity  which  the  consolidated  lung  presents.  Any 
condition,  by  causing  consolidation  of  the  lung,  obliterating  the  air 
spaces,  may  produce  bronchial  breathing.  Thus  bronchial  breathing 
of  the  most  pronounced  type  may  be  found  over  a  pleural  sac  filled  with 
fluid.  The  lungs  solidified  by  the  pneumonia  or  compressed  by  fluid 
(carnified)  give  rise  to  bronchial  breathing  which  is  readily  transmitted 
by  the  fluid  under  compression  to  the  surface  of  the  chest- wall.  Bron- 
chial breathing  heard  all  over  the  chest  (front,  back,  axilla,  and  apex) 
almost  without  exception  means  that  the  pleural  cavity  is  filled  with 


EXAMINATION    OF    LUNGS 


307 


fluid.  A  failing  to  recognize  fluid  under  marked  signs  of  general 
bronchial  breathing  is  one  of  the  most  frequent  errors  made  in  chest 
diagnosis  in  children. 

Bronchovesicular  Breathing. — I  do  not  recognize  bronchovesicular 
breathing  as  a  distinct  type,  but  one  of  the  forms  of  weakened  or  defec- 
tive breathing. 

In  emphysematous  breathing  the  inspiration  is  short  and  somewhat 
feeble,  but  not  otherwise  remarkable.  The  expiration  is  long,  feeble, 
and  low  pitched. 

Asthmatic  breathing  differs  from  emphysematous  breathing,  the 
latter  being  characterized  by  greater  intensity  of  inspiration.  In 
asthmatic  breathing,  however,  both  sounds  are  usually  obscured  to  a 
great  extent  by  the  presence  of  piping  and  squeaking  rales. 

Cavernous  Breathing. — -Cavernous  or  amphoric  breathing  will  be 
found  over  a  cavity  or  a  large  bronchiectasis.  The  respiratory  sound 
has  a  peculiar  hollow  quality,  both  upon  inspiration  and  upon  expira- 
tion. A  low  note  is  produced  which  has  been  compared  to  the  sound 
produced  by  blowing  gently  into  a  wide-mouthed  bottle. 


Fig.  37. — Emphysematous  breathing. 


Fig.  38. — Asthmatic  breathing:  s,  s,  s, 
squeaking   (musical)   riles. 


Rales. — Upon  auscultation  of  the  lungs  rales  of  different  kinds  will 
be  heard.  A  rale  is  the  sound  produced  by  impeded  air  in  its  passage 
through  a  bronchus  to  the  lung.  This  may  be  brought  about  through 
a  spasm  of  the  tube,  through  thickening  of  its  mucous  membrane,  or 
the  presence  of  pus,  mucus,  or  water  in  the  bronchial  tube.  Rales 
of  various  types  will  be  produced,  depending  upon  the  nature  of  the 
lesion  and  the  size  of  the  tube  affected.  Thus  when  there  is  congestion 
with  infiltration,  there  will  be  sonorous  rales  in  the  large  tubes  and 
sibilant  rales  in  the  smaller  tubes. 

Sonorous  rales  are  low-pitched  snoring  sounds,  roughened  and  grat- 
ing in  character.     Stridor  in  laryngitis  is  akin  to  the  sonorous  rales. 

Sibilant  rales  are  squeaking,  hissing,  and  crackling  in  character. 
In  the  smaller  tubes  they  indicate  the  same  condition  as  is  productive 
of  the  sonorous  rales  in  the  large  tubes,  with  this  difference,  that  the 
advent  of  bronchial  spasm  is  a  considerable  factor  in  the  production  of 
sibilant  rales.  Sibilant  rales  are  almost  always  present  in  asthma  and 
in  asthmatic  bronchitis,  and  may  indicate  an  early  stage  of  bronchitis. 

Mucous  or  Moist  Rales. — Mucous  or  moist  rales  are  large,  medium, 
and  small;  and  vary  in  size  and  number,  depending  upon  the  nature 
of  the  lesion.     They  are  produced  by  the  passage  of  air  through 


308  THE    PRACTICE    OF    PEDIATRICS 

diseased  bronchi  containing  exudation,  and  are  present  in  all  catarrhal 
conditions  of  the  lung  from  whatever  cause.  In  bronchitis  and 
bronchopneumonia,  if  the  examiner  is  sufficiently  industrious,  every 
variety  of  rale  may  at  some  time  be  heard. 

The  Stethoscope. — The  stethoscope  (Fig.  39)  is  the  best  instrument 
for  use  with  children.  There  are  two  requirements  which  every 
stethoscope  should  fulfil.     The  ear-pieces  must  fit  the  ear,  and  the 


Fig.  39. — Stethoscope. 

pressure  of. the  spring  should  be  sufficient  to  hold  them  in  position 
without  causing  discomfort.  Flexible  rubber  connecting  tubes  are 
preferred.  They  should  be  from  9  to  12  inches  in  length,  thus  allowing 
the  operator  to  move  the  bell  freely  over  the  chest  without  following  the 
instrument  with  his  head.  The  long  tubes  are  further  better  in  that 
they  permit  the  physician's  head  to  remain  at  greater  distance  from  the 
child,  thus  preventing  fright  in  a  timid  patient.     The  chest-piece  or 


EXAMINATION   OF   LUNGS 


309 


bell  should  be  small,  so  as  to  fit  snugly  the  chests  of  thin  children.     The 
diameter  of  the  bell  employed  in  my  own  work  is  iKe  inch. 

The  Bowles  stethoscope  (Fig.  40)  differs  from  the  foregoing  in  the 
shape  of  the  chest-piece,  which  consists  of  a  flat,  saucer-shaped  piece 
of  metal,  the  orifice  of  which  is  covered  over  by  a  thin  metal  diaphragm. 
The  only  advantage  possessed  by  this  device  is  that  it  enables  the  phy- 
sician to  examine  the  child  without  the  change  of  position  and  other 
manipulation  necessary  in  using  the  instrument  first  described.     For 


Fig.  40. — The  Bowles  stethoscope. 


this  reason  the  Bowles  stethoscope  is  useful  with  children  desperately 
ill,  for  whom  such  manipulation  is  not  a  safe  or  desirable  procedure. 
The  flat  chest-piece  which  is  attached  to  a  flexible  tube  can  readily  be 
slipped  under  the  child,  and  the  examination  conducted  with  the  least 
possible  disturbance.  This  stethoscope,  however,  should  not  be  used 
in  routine  examination,  as  it  accentuates  all  the  chest  and  heart-sounds, 
(which  in  children  are  sufficiently  plain  to  be  detected  by  the  ordinary 
instrument),  and  gives  an  exaggerated  impression  of  the  intensity  of  a 
normal  sound.  In  instances  in  which  there  is  weakness  of  the  respira- 
tory or  cardiac  sounds,  this  instrument  may  be  of  service. 


310  THE    PRACTICE    OF    PEDIATRICS 


BRONCHITIS 


Acute  bronchitis,  an  infection  of  the  bronchial  mucous  membrane, 
occurs  with  great  frequency  in  infants  and  young  children. 

The  majority  of  cases  occur  during  the  colder  months  of  the  year, 
when  houses  are  overheated,  and  when  sudden  changes  in  the  weather 
are  frequent..  The  sudden  advent  of  exposure  lowers  the  child 's  resist- 
ance, and  the  infecting  agents  which  are  always  present  are  then  given 
a  favorable  field  for  activity. 

Predisposing  Causes. — The  chief  predisposing  cause  is  absence  of 
resistance  to  bacterial  invasion — a  condition  peculiar  to  child  life. 

Infants  and  children  who  are  rachitic  or  who  suffer  from  other  forms 
of  malnutrition  are  particularly  susceptible.  Chronic  rhinitis,  enlarged 
tonsils,  and  adenoids  are  predisposing  factors  of  no  small  consequence. 

Bacteriology. — The  usual  bacteriologic  agents  are  the  pneumococcus, 
the  influenza  bacillus,  the  staphylococcus,  and  the  streptococcus. 

Types. — Bronchitis  may  be  divided  clinically  into  three  types: 
Primary,  secondary,  and  chronic. 

Primary. — Asthmatic  (p.  316). — Simple. — In  simple  primary  bron- 
chitis there  may  have  been  an  exposure  to  cold  or  wet,  although  this  is 
not  at  all  necessary.  The  disease  is  more  apt  to  follow  exposure  to 
another  individual  who  has  a  so-called  "  cold,"  and  who  is,  temporarily, 
at  least,  a  germ  carrier. 

Secondary. — This  type  is  most  often  found  associated  with  measles, 
whooping-cough,  and  grip,  or  following  an  acute  catarrhal  infection  of 
the  upper  respiratory  tract. 

Chronic. — Chronic  bronchitis  is  somewhat  rare  in  the  young.  It 
occurs  most  frequently  in  conjunction  with  asthma,  or  in  slow  con- 
valescence after  bronchopneumonia,  and  is  always  present  in  chronic 
pulmonary  tuberculosis. 

Pathology. — In  simple  bronchitis  the  lesion  is  very  slight.  The 
mucous  membrane  may  show  congestion  and  slight  round-cell  infiltra- 
tion, and  there  may  be  elevation  or  loss  of  superficial  epithelium  in 
small  areas  where  the  infection  is  most  severe. 

Symptoms. — The  onset  of  acute  bronchitis  is  usually  sudden; 
There  is  cough,  which  may  be  extremely  troublesome,  interfering  with 
sleep,  and,  in  the  case  of  young  infants,  rendering  the  nursing  and 
bottle  feeding  difficult.  The  respirations  are  rarely  accelerated  above 
30  per  minute  unless  there  is  an  associated  bronchial  spasm.  (See  p. 
316.)  There  may  be  moderate  prostration;  in  mild  cases  there  is  none. 
In  severe  cases  the  appetite  is  interfered  with.  The  child  is  rather 
peevish  and  shows  general  discomfort. 

Fever. — The  usual  range  of  the  fever  in  uncomplicated  bronchitis , 
is  from  100°  to  102°F.  When  the  temperature  remains  above  102°F., 
or  makes  frequent  excursions  above  this  point,  I  have  always  found 
a  complication  of  some  kind — something  other  than  bronchitis — to 
account  for  the  temperature.  Frequent  sources  are  some  intestinal 
disorder,  a  developing  otitis,  or  a  beginning  bronchopneumonia.     If 


BKONCHITIS  311 

the  temperature  ranges  above  102°F.  and  the  respiration  is  40  or  more, 
we  may  be  almost  certain  of  a  developing  pneumonia. 

Physical  Signs. — Auscultation  of  the  chest  early  in  an  attack  will 
reveal  a  harsh,  roughened  respiratory  murmur,  fairly  evenly  distrib- 
uted all  over  the  lungs.  Sonorous,  sibilant,  and  mucous  rales  become 
audible  in  from  twelve  to  thirty-six  hours. 

Percussion. —There  is  no  change  in  the  percussion-notes  except  in 
the  cases  of  asthmatic  bronchitis  (p.  316),  which  show  hyperresonance 
or  tympanitic  dulness. 

Palpation  is  here  of  no  aid. 

Duration.^ — -The  duration  of  an  attack  of  bronchitis  depends  to  some 
extent  upon  the  child's  recuperative  powers,  but  to  a  much  greater 
degree  upon  the  method  of  treatment.  A  primary  case  properly  man- 
aged should  be  well  in  five  days.  Many  cases  are  not  treated  at  all 
by  a  physician.  It  is  these  cases  of  neglected  bronchitis  which  furnish 
a  great  majority  of  our  cases  of  bronchopneumonia,  a  disease  which 
contributes  largely  to  the  mortality  of  children  under  five  years  of  age. 

Diagnosis. — Signs  of  consolidation  in  the  lung  are  not  necessary 
for  the  diagnosis  of  pneumonia.  Cases  very  often  reported  as  those 
of  capillary  bronchitis,  in  which  there  is  rapid  breathing,- — 40  to  60  a 
minute,— high  temperature, — 103°  to  105°F., — and  marked  prostra- 
tion, show  at  autopsy  the  pneumonic  elements  which  gave  during  life 
no  other  signs  in  the  chest  than  a  diminished  respiratory  murmur  and 
many  fine  mucous  rales.  Catarrh  of  the  bronchial  tubes,  manifested 
by  many  rales  of  different  types,  is  the  chief  diagnostic  feature  of  the 
disease. 

Secondary  bronchitis  differs  from  the  acute  primary  form  only  in 
the  mode  of  onset.  In  the  secondary  type  the  onset  is  gradual — three 
or  more  days  usually  being  required  before  the  disease  is  well  advanced. 

In  chronic  bronchitis  the  physical  signs  consist  of  various  types  of 
mucous  rales  in  the  bronchi.  The  medium-sized  bronchi  are,  as  a  rule, 
the  chief  seat  of  this  catarrhal  process. 

Cough  is  the  most  active  symptom,  and  is  worse  at  night.  Fever, 
if  present,  is  due  to  the  associated  disease,  as  chronic  bronchitis  in  a 
child  is  rarely  an  independent  illness. 

Treatment.- — ^The  management  of  the  primary  and  secondary  cases 
is,  in  the  main,  the  same,  varying,  of  course,  to  meet  individual  condi- 
tions or  symptoms. 

Before  indicating  what  should  be  done  in  a  case  of  bronchitis  it  may 
be  as  important,  by  way  of  emphasis,  to  advise  what  not  to  do.  Do 
not  seal  the  room  up  tight  by  keeping  all  the  windows  closed.  Do  not 
use  an  oil-silk  jacket  lined  with  wadding  or  any  other  material.  Do 
not  allow  the  child  to  be  wrapped  in  blankets  and  shawls  and  held 
against  a  warm  adult  body.  Do  not  give  the  child  large  doses  of  so- 
called  "  expectorants  " — a  teaspoonful  of  a  heavy  syrup.  The  tempera- 
ture of  the  room  should  be  kept  as  near  68°F.  as  possible.  There 
should  always  be  direct  communication  with  the  open  air.  A  window 
lowered  an  inch  or  two  from  the  top,  or  the  window-board  described 


312  THE    PRACTICE    OF   PEDIATRICS 

on  p.  138,  is  a  safe  means  of  assisting  in  ventilation.  The  child  should 
be  kept  in  his  crib  and  wear  the  night-clothing  to  which  he  was 
accustomed  in  health.  Many  children  with  bronchitis  do  not  feel 
particularly  ill  and  rebel  against  the  enforced  inactivity.  A  patient 
who  can  not  be  kept  under  the  covers  may  wear  a  pinning-blanket 
or  a  bath-robe  while  sitting  up  in  bed,  but  should  not  be  allowed 
to  sleep  in  either. 

The  Diet. — If  there  is  little  or  no  fever,  the  diet  need  be  reduced 
but  little.  If  there  is  fever,  100°  to  101. 5°F.,  with  restlessness  and 
irritability,  the  food  should  be  reduced  in  strength,  the  same  amount 
of  fluid  being  allowed  as  in  health,  the  reduction  being  made  by  giving 
plain  boiled  water  frequently  to  drink  between  the  feedings.  The 
diet  of  a  nursing  baby  can  best  be  reduced  by  giving  a  drink  of  water 
before  each  nursing,  and  shortening  the  time  allowed  for  nursing  from 
one-third  to  one-half.  We  will  thus  avoid  digestive  disturbances, 
which  often  act  as  a  very  serious  complication  of  the  existing  disorder. 
Older  children,  receiving  a  mixed  diet,  may  be  given  toast,  cocoa,  milk, 
broths,  gruels,  and  fruit-juices. 

Steam  Inhalations. — Properly  administered  medicated  steam  in- 
halations are  of  greater  service  in  bronchitis,  particularly  in  young 
infants,  than  any  other  form  of  treatment  which  we  possess.  The 
steaming  is  best  administered  with  the  child  placed  in  the  crib, 
which  is  covered  and  draped  with  sheets.  A  croup  kettle  with 
alcohol  lamp  attachment  is  the  most  convenient  means  for  gener- 
ating steam.  The  nozzle  of  the  croup  kettle,  which  rests  on  a  chair  or 
stand,  is  carried  under  the  tent  at  a  safe  distance  from  the  child's  hands 
and  face.  For  inhalation,  creosote  has  given  better  results  than  has 
any  other  drug.  Ten  drops  are  added  to  one  quart  of  boiling  water 
and  the  steaming  is  continued  for  thirty  minutes.  Ordinarily,  in  an 
urgent  case,  steaming  for  thirty  minutes  is  given  at  two-and-a-half -hour 
intervals  day  and  night  until  the  child  recovers.  Older  children,  and 
those  in  whom  the  condition  is  not  grave,  need  not  receive  the  steam 
after  the  bedtime  of  mother  or  nurse.  It  is  well  to  allow  a  change  of 
air  in  the  inclosed  space  at  least  three  times  during  the  steaming. 
This  is,  done  by  raising  the  sheet  for  a  moment  or  two  and  then  replac- 
ing it.     The  side  of  the  crib,  if  preferred,  need  not  be  draped. 

Counterirritation. — Counterirritation  of  the  skin  over  the  thorax  is 
another  very  useful  method  of  treatment  in  bronchitis.  Full  instruc- 
tions must  be  given  the  mother  and  nurse  as  to  how  the  counterirri- 
tant  is  to  be  applied,  or  the  application  will  be  very  indifferently  made. 
In  my  hands  the  mustard  plaster  has  been  the  most  convenient  means 
of  counterirritation,  and  has  given  the  best  results.  It  is  well  to  begin 
with  a  strength  of  one  part  of  mustard  and  two  parts  of  flour.  Two 
or  three  applications  of  this  strength  may  be  made.  Later,  when  the 
skin  becomes  sensitive,  the  plaster  is  to  be  made  weaker  by  the  addition 
of  more  flour,  one  part  of  mustard  to  five  or  six  of  flour.  In  order  to 
be  effective  the  plaster  should  remain  in  contact  with  the  skin  from 
five  to  fifteen  minutes,  until  a  diffuse  blush  appears.     The  plaster  is 


BRONCHITIS  313 

prepared  as  follows:  Mix  the  mustard  and  the  flour,  using  hot  water 
until  a  paste  of  medium  thickness  is  formed.  This  is  to  be  spread  on 
cheese-cloth,  old  linen,  or  thin  white  muslin,  to  a  thickness  of  about 
3^  inch.  Over  this  one  thickness  of  cheese-cloth  should  be  placed. 
The  size  of  the  plaster  depends  upon  the  age  of  the  child  and  the  area 
of  lung  involved.  In  a  case  of  general  bronchitis  the  entire  thorax, 
front  and  back,  should  be  covered.  It  is  easier  to  make  two  plasters 
which  meet  under  the  arms  than  to  make  one  to  encircle  the  thorax, 
as  is  sometimes  done.  A  circle  is  cut  out  for  the  arms  at  the  upper 
corners.  The  plasters  are  sufficiently  large  to  meet  at  the  sides,  as 
mentioned  above,  when  they  may  be  pinned  together.  When  all  is 
completed,  the  application  really  amounts  to  a  mustard  jacket.  The 
plaster  may  be  applied  from  two  to  four  times  daily,  depending  upon 
the  urgency  of  the  case.  Counterirritation  thus  made  is  of  great  ser- 
vice early  in  the  attack — during  the  stage  of  acute  congestion.  I 
question  whether  plasters  are  of  much  use  after  two  or  three  days  have 
elapsed.  After  removal  of  the  plaster  an  application  of  vaselin  is 
grateful  to  the  patient. 

Mustard  Baths. — A  mustard  bath,  }^  ounce  of  mustard  to  6  gallons 
of  water,  at  a  temperature  of  110°F.,  is  of  considerable  service  in  the 
very  acute  cases  in  young  children,  with  extensive  involvement  of  the 
fine  tubes,  usually  known  as  ''capillary  bronchitis,"  in  which  there  is 
a  great  deal  of  bronchial  spasm.  This  condition  is  very  apt  to  develop 
into  bronchopneumonia,  even  if  the  pneumonia  does  not  exist  from 
the  beginning,  which  is  probably  the  case.  There  is  considerable 
shock;  the  hands  and  feet  are  often  cold;  the  respiration  is  rapid,  and 
the  child  is  considerably  prostrated.  The  bath  may  be  repeated  with 
advantage  at  intervals  of  from  six  to  eight  hours.  The  child  is  to 
remain  in  the  bath  from  one  to  three  minutes.  While  in  the  bath  the 
trunk  and  extremities  should  be  briskly  rubbed  with  the  bare  hand. 

Drugs. — The  value  of  drugs  in  the  management  of  this  disease  has 
been  considerably  overestimated,  and  they  are  mentioned  last  because 
they  are  the  least  important  of  the  remedial  agents  referred  to. 

During  the  first  stage  of  bronchitis,  that  of  engorgement,  indicated 
by  a  short,  dry  cough,  and  rough,  sonorous  breathing,  small  doses  of 
castor  oil  and  syrup  of  ipecac  constitute  our  best  medication.  From 
the  first  to  the  third  year,  two  to  three  drops  of  castor  oil  and  two  to 
three  drops  of  syrup  of  ipecac  may  be  given  every  two  hours ;  after  the 
third  year,  three  drops  of  syrup  of  ipecac  and  five  drops  of  castor  oil 
every  two  hours.  At  least  eight  doses  should  be  given  in  twenty-four 
hours.  Ordinarily,  after  twenty-four  hours,  auscultation  will  reveal 
a  freer  secretion  in  the  bronchi,  the  fever  will  diminish,  and  the  child's 
cough  will  become  loose  and  less  severe.  The  benefits  from  the  oil 
and  ipecac  will  be  obtained  in  from  forty-two  to  seventy-two  hours, 
after  which  this  medication  should  be  discontinued. 

If  the  cough  and  the  chest  sounds  tell  us  that  the  bronchi  are  not 
yet  clear,  a  combination  of  tartar  emetic,  powdered  ipecac,  and  am- 
monium chlorid  may  be  used.     To  a  child  under  six  months  of  age  a 


314  THE    PRACTICE    OF    PEDIATRICS 

powder  or  tablet  containing  3-1 50  grain  of  tartar  emetic,  ^io  grain  of 
powdered  ipecac,  and  j^-^t  grain  of  ammonium  chlorid  should  be  given 
at  two-hour  intervals,  eight  doses  in  twenty-four  hours;  from  six 
months  to  one  year,  tartar  emetic,  /-f  00  grain;  powdered  ipecac,  3^o 
grain;  ammonium  chlorid,  3^  grain,  at  two-hour  intervals,  eight  doses 
in  twenty-four  hours.  If  the  cough  is  very  annoying  and  severe,  re- 
quiring a  sedative,  3^^  grain  of  Dover's  powder  may  be  added  to  each 
dose  for  children  under  six  months,  and  J-^  grain  for  children  over  six 
months  of  age.  From  one  to  three  years  of  age,  tartar  emetic,  /-f  00 
grain;  powdered  ipecac,  3^o  grain;  ammonium  chlorid,  J-^  grain,  may 
be  given  at  two-hour  intervals,  eight  doses  in  twenty-four  hours,  ^•^ 
grain  of  Dover's  powder  to  be  added  to  each  dose  if  the  character  of 
the  cough  demands  it.  The  tablet  or  powder,  whichever  is  employed, 
should  be  given  in  two  teaspoonfuls  of  thin  gruel  or  plain  water. 
After  the  third  year  ^-^o  grain  of  tartar  emetic,  }-^o  grain  of  pulverized 
ipecac,  and  1  grain  of  ammonium  chlorid  may  be  given  every  two  hours, 
eight  doses  in  the  twenty-four  hours.  The  use  of  tablets  or  powders 
should  be  insisted  upon,  particularly  in  treating  very  young  children. 
The  large  doses  of  ammonium  salts  and  ipecac  in  heavy  syrups  are  to 
be  avoided  because  of  their  liability  to  produce  stomach  disturbance. 

The  treatment  of  secondary  bronchitis  depends  to  a  certain  extent 
upon  the  disease  with  which  it  is  associated,  and  the  treatment  should 
be  modified  accordingly.  Counterirritation  and  medicated  steam  in- 
halations ordinarily  can  be  used,  as  they  interfere  but  little  with  other 
necessary  treatment. 

Treatment  of  Chronic  Cases. — In  chronic  bronchitis  the  removal  of 
enlarged  tonsils  and  adenoids,  fresh  air,  and  change  to  a  dry  climate, 
if  possible,  are  our  best  means  of  treatment.  In  addition,  general  sup- 
portive treatment  is  to  be  advised.  (See  The  Management  of  Delicate 
Children.)  Creasote  in  small  doses,  1  to  3  minims  after  meals,  for  a 
child  from  two  to  five  years  of  age,  has  seemed  to  me  to  be  of  service 
with  some  of  these  children.  My  greatest  success,  however,  with 
these  cases  has  been  achieved  by  ignoring  the  bronchitis  temporarily 
and  putting  the  child  in  the  best  hygienic  surroundings.  Outdoor  life 
inland  and  a  nutritious  diet  are  far  better  than  drugs.  In  many  of 
these  cases,  under  such  a  regime,  the  disease  for  which  the  child  was 
brought  for  treatment  has  entirely  disappeared  without  any  specific 
medication  whatever,  showing  that  the  bronchial  catarrh  was  nothing 
more  or  less  than  a  manifestation  of  greatly  reduced  vitality. 

Differential  Diagnosis. — Chronic  bronchitis  may  be  differentiated 
from  pulmonary  tuberculosis  by  the  temperature  range,  elevation  of 
the  temperature  being  absent  in  bronchitis.  The  examination  of  the 
sputum  and  the  von  Pirquet  skin  test  are  sufficient  to  establish  a 
diagnosis. 

RECURRENT  BRONCHITIS 

Recurrent  bronchitis  without  the  association  of  asthma  and  without 
fever  or  prostration  is  occasionally  encountered.  A  typical  case  of 
this  kind  is  as  follows; 


RECURRENT  BRONCHITIS  315 

Illustrative  Case. — A  plump,  well-nourished,  four-year-old  girl  had  a  history  of 
attacks  of  bronchitis  lasting  from  five  to  seven  days  at  intervals  of  not  longer  than 
three  weeks.  The  physical  examination  was  negative.  The  attacks  commenced 
when  she  was  two  years  of  age  and  had  continued  for  two  years.  There  never  was 
a  temperature  of  over  100°F.  with  the  attacks,  and  the  child  was  not  physically  ill. 
There  had  never  been  cyclic  vomiting,  tonsillitis,  or  rheumatism.  The  father  was 
a  sufferer  from  chronic  rheumatism.  The  patient  was  given  a  diet  suitable  for  her 
age  (p.  108),  meat  being  allowed  every  second  day.  The  considerable  quantity  of 
sugar  which  she  had  been  taking  was  greatly  reduced,  only  enough  being  allowed  to 
make  the  food  palatable.     She  was  given  the  following  prescription: 

I^    Sodii  salicylatis  (wintergreen) gr.  xxxvj 

Sodii  bicarbonatis gr.  Ixxij 

Elix.  simplicis 3v 

Aquae q.  s.  ad  5 ij 

M.  Sig. — One  teaspoonful  twice  daily  after  meals. 

The  above  prescription  was  given  for  five  days,  followed  by  an  interval  of  five 
days'  rest.  This  procedure  was  continued  for  five  months,  during  which  time 
there  was  no  bronchitis.  Later  this  medication  was  given  ten  days  each  month  for 
one  year,  with  entire  relief  of  the  trouble.  Withholding  sugar  and  fat  from  the  diet 
was  continued  indefinitely.     The  patient  has  had  no  further  inconvenience. 

When  a  child  develops  joint  or  bone  diseases,  the  family  can  usu- 
ally recall  an  injury  or  fall  of  some  sort  to  account  for  the  trouble. 
So,  also,  in  the  event  of  bronchitis,  an  exposure,  a  change  of  clothing, 
or  a  change  in  the  weather  will  usually  be  regarded  as  a  cause  of  the 
attack. 

In  the  case  above  cited,  and  in  many  others,  such  factors  evidently 
have  had  very  little,  if  anything,  to  do  with  the  bronchitis,  for  under 
the  same  climatic  conditions  the  attacks  cease  when  attention  is  given 
to  the  constitutional  condition,  and  proper  diet  and  medication  are 
prescribed.     The  patients  are  usually  of  gouty  or  rheumatic  ancestry. 

Treatment. — I  have  successfully  treated  a  large  number  of  these 
children.     Sugar  and  fat  cannot  be  taken  by  them. 

They  should  lead  an  active  outdoor  life  when  climatic  conditions 
allow.  There  should  always  be  communication  between  the  sleeping- 
room  and  the  outer  air.  All  possible  influencing  factors,  such  as  en- 
larged tonsils  and  adenoids,  are  to  be  removed.  (This  operation, 
however,  is  never  sufiicient  in  itself  to  prevent  recurrences.) 

Diet. — Red  meats,  including  beef,  mutton,  and  lamb,  should  be 
given  only  every  second  or  third  day.  Sugar  is  permissible  only  in 
sufficient  amount  to  make  the  food  palatable.  If  the  case  resists 
treatment,  sugar  is  to  be  discontinued  and  saccharin  substituted. 
Skimmed  milk  may  be  given  as  a  drink,  eight  ounces  being  allowed 
both  for  breakfast  and  for  supper.  Green  vegetables  and  cereals  well 
cooked  and  suitable  for  the  age  may  be  given  freely. 

There  must  be  a  free  evacuation  of  the  bowels  daily.  If  there  is  a 
tendency  to  constipation,  the  management  suggested  on  page  244  is 
to  be  brought  into  use. 

Medication. — These  patients  are  not  influenced  by  the  usual  treat- 
ment for  bronchitis,  so  that  expectorant  drugs  may  be  omitted.  Large 
doses  of  bicarbonate  of  soda  do  more  toward  shortening  the  attacks 
than  do  any  other  forms  of  medication.  To  a  child  five  years  of  age 
ten  grains  should  be  given  at  two-hour  intervals. 

The  interval  treatment,  with  diet,  must  be  relied  upon  to  prevent 


316  THE    PRACTICE    OF    PEDIATRICS 

a  recurrence  of  the  attacks.  Salicylate  of  soda  (wintergreen)  is  given 
for  five  days,  in  doses  of  from  three  to  five  grains,  well  diluted,  after 
meals.  The  salicylate  is  then  discontinued  and  the  bicarbonate  is 
given  for  ten  days  in  the  same  dosage,  when  the  salicylate  is  lesumed. 
In  this  way,  by  alternating  the  two  drugs  or  by  giving  aspirin  when 
the  salicylate  disagrees,  the  treatment  is  continued  for  two  or  three 
months.  As  the  case  improves,  an  interval  of  rest  from  all  medication 
is  instituted.  If  it  is  more  convenient,  the  salicylate  and  the  bicar- 
bonate of  soda  may  be  given  at  the  same  time. 

Bathing. — rThe  skin  in  these  cases  should  be  kept  active,  and  once 
daily  the  child  should  be  given  a  tub-bath  in  lukewarm  water.  After 
the  bath  a  cool  spray  or  spinal  douche  is  used,  the  temperature  of  the 
water  ranging  from  50°  to  70°F.  An  excessive  degree  of  cold  is  not 
ad\asable;  it  should  be  sufficient,  however,  to  insure  good  reaction 
after  a  brisk  rubbing  with  a  rough  towel. 

ACUTE  SPASMODIC  BRONCHITIS  (BRONCHIAL  ASTHMA) 

Infants  and  young  children  may  suffer  from  spasmodic  attacks  of 
dyspnea — the  manifestation  of  the  disease  in  the  adult.  With  asthma 
in  the  child,  regardless  of  age,  there  is  almost  invariably  an  association 
of  bronchitis.  In  some  the  nervous  phenomenon  of  spasm  predomi- 
nates with  little  bronchial  involvement.  In  others  there  is  consider- 
able bronchitis,  with  slight,  moderate,  or  intense  spasm.  In  the  case 
of  the  infant  and  very  young  child  the  term  "capillary  bronchitis"  has 
been  given  to  two  distinct  conditions.  In  one  there  is  an  acute  spas- 
modic bronchitis,  and  in  the  other  an  acute  pneumococcus  infection  of 
the  lungs  without  localization.  In  acute  asthmatic  bronchitis  the 
mode  of  onset,  the  lesions,  and  the  fever  are  all  as  found  in  acute 
simple  bronchitis.  The  bronchial  spasm,  however,  differentiates  the 
two  forms  from  two  standpoints:  First,  the  respiration  in  the  asth- 
matic type  is  very  rapid — I  have  repeatedly  seen  it  at  80  to  100;  60  is 
the  rule.  Secondly,  the  chest  signs  are  most  dissimilar.  In  the  spas- 
modic cases  there  may  be  an  entire  absence  of,  or  very  feeble,  respira- 
tory murmur,  with  inspiration  short  and  squeaking  in  character,  while 
the  expiration  is  prolonged  and  accompanied  by  fine  sibilant  rales. 
These  signs  may  be  locaHzed  in  one  lung  or  a  portion  of  a  lung,  or  may 
occur  in  both  lungs,  as  I  have  observed  time  and  again,  the  same  aus- 
cultatory signs  occurring  over  the  entire  chest.  There  is  but  little 
action  of  the  respiratory  muscles;  the  chest  appears  held  in  fixed  posi- 
tion. The  dyspnea  may  be  extreme,  and  the  child  suffers  from  air- 
hunger.  Both  the  entrance  and  exit  of  air  are  impeded.  Cyanosis, 
profuse  perspiration,  and  marked  prostration  are  apparent  if  the  attack 
is  prolonged. 

Percussion  elicits  hyperresonance  or  tympanitic  dulness.  This 
type  of  bronchitis  may  occur  in  the  youngest  infant.  I  have  older 
children  as  patients  who  always  have  the  spasmodic  condition  when 
there  is  a  bronchitis. 

Etiology. — In  asthmatic  infants  and  children  there  is  an  undoubted 
gouty  (lithemic)  diathesis.     Not  only  are  these  children  subject  to 


ACUTE   SPASMODIC  BRONCHITIS    (BRONCHIAL  ASTHMA)       317 

bronchitis  of  the  spasmodic  type,  but  they  also  have  or  may  have  at- 
tacks of  croup,  eczema,  cyclic  vomiting,  periodic  fever,  and  periodic 
intestinal  crises,  with  or  without  fever,  and  with  or  without  gastric 
crises.  I  have  under  my  care  a  patient  who  suffered  intensely  from 
eczema  when  an  infant  and  who  later  developed  cyclic  spasmodic 
bronchitis  of  a  very  severe  type,  usually  combined  with  spasmodic 
croup  and  cyclic  vomiting.  This  child  kept  her  physician  father  very 
busy.  When  she  was  not  doing  one  turn,  she  was  doing  another,  and 
all  came  without  warning.  The  child  was  of  a  markedly  gouty  an- 
cestry, I  have  had  other  cases  as  pronounced  as  this  one.  Most 
important  dietetic  factors  in  these  cases  are  fat  and  sugar,  particularly 
cow's  milk-fat  and  cane-sugar.  These  patients  during  the  asthmatic 
attack  will  develop  the  acetone  breath,  but  not  to  the  degree  that  is 
seen  in  cyclic  vomiting  (true  acidosis). 

Illustrative  Cases. — Case  1. — A  girl  eight  years  of  age  was  brought  to  me 
with  the  history  of  an  attack  of  asthmatic  bronchitis  every  month  for  several 
years.  The  asthma  was  not  severe.  It  was  present  at  the  onset  of  the  at- 
tack, and  lasted  for  perhaps  twenty-four  hours.  The  bronchitis  usually  cleared 
up  in  about  five  days.  She  had  spent  but  little  time  in  New  York  because  of  her 
so-called  frequent  "colds."  Her  mother  brought  the  child  to  me  in  view  of  a 
contemplated  change  of  residence.  In  Florida  and  lower  California,  where  the 
patient  had  passed  the  winter,  the  attacks  had  occurred,  but  were  mild  in  character. 
As  soon  as  she  returned  home  the  attacks  returned,  keeping  her  from  school  for  one 
week  out  of  every  four  or  five.  In  taking  the  personal  history  the  matter  of 
adenoids  and  tonsils  was  mentioned,  when  the  mother  hastened  to  inform  me  that 
the  adenoids  and  tonsils  had  been  removed  twice,  thus  demonstrating  that  they 
were  not  a  factor  in  the  case.  The  child  had  never  suffered  from  rheumatism  or 
cyclic  vomiting.  Aside  from  revealing  a  mild  secondary  anemia  and  slight 
emphysema,  the  physical  examination  proved  negative.  The  family  history 
disclosed  that  all  the  child's  antecedents  on  both  sides,  for  three  generations,  had 
suffered  either  from  rheumatism  or  gout.  Her  mother  had  been  a  life-long 
sufferer  from  rheumatism.  Upon  close  questioning,  it  was  found  that  the  child's 
diet  consisted  of  red  meat  twice  daily;  she  disliked  vegetables,  took  cereals  only 
when  covered  with  sugar,  and  drank  milk  only  when  two  teaspoonfuls  of  sugar 
were  added  to  each  glass.  She  had  candy  and  cake  ad  libitum.  She  was  recovering 
from  an  attack  of  bronchitis  when  I  saw  her,  and  was  taking  an  expectorant  cough- 
syrup.  This  was  discontinued,  red  meat  was  permitted  but  twice  a  week,  the 
sugar  was  largely  reduced,  saccharin  being  used  in  the  milk  to  satisfy  the  abnormal 
craving  for  sweets.  She  was  bribed  by  the  mother  to  eat  green  vegetables  and 
cereals.  The  desserts  consisted  largely  of  stewed  fruits  flavored  with  saccharin. 
Candy,  cake,  and  pastry  were  forbidden.  She  was  given  4  grains  of  the  salicylate 
of  soda  (wintergreen)  three  times  daily  for  five  days,  which  was  followed  by  10 
grains  of  the  bicarbonate  three  times  dailj^  for  five  days;  then  for  five  days  there 
was  no  medication.  This  treatment  was  continued  for  six  months.  During 
the  following  six  months  the  salicylate  and  the  bicai'bonate  of  soda  were  given  but 
five  days  each  out  of  each  month.  During  the  entire  year  but  one  mild  attack  of 
bronchial  asthma  occurred. 

Case  2. — A  most  striking  case  of  periodic  asthmatic  bronchitis  occurred  in  a 
boy  nine  years  of  age.  The  father  had  had  inflammatory  rheumatism.  Of  the 
mother's  family,  the  grandmother  was  an  invalid  with  rheumatism  and  the  grand- 
father was  troubled  slightly  with  it. 

The  boy  was  pale,  but  well  nourished,  weighing  68  pounds.  He  was  verj^  active 
mentally.  He  had  had  chicken-pox  and  one  attack  of  tonsillitis.  The  blood 
examination  showed  78  per  cent,  of  hemoglobin,  5,500,000  red  cells,  and  8,000 
leukocytes.  The  urine  was  negative.  During  the  previous  j'car  he  had  had  a 
great  many  attacks  of  asthmatic  bronchitis.  The  mother  stated  that  they  occurred 
once  every  three  or  four  weeks.  Previous  to  this  time  there  had  Ijeen  very  frequent 
colds — so  many  that  the  boy's  attendance  at  school  had  been  practically  nil.  The 
mother  had  discovered  that  sugar  did  not  agree,  and  very  little  had  been  given. 
He  was  very  fond  of  red  meat,  liowever,  and  wanted  it  three  times  a  day.  He  was 
given  the  meat  twice  a  day. 


318  THE    PRACTICE    OF    PEDIATRICS 

A  liberal  diet  of  green  vegetables,  fruits,  milk,  and  cereals  was  ordered.  In 
addition,  eggs  or  bacon  were  to  be  given  for  breakfast,  red  meat  three  times  a  week, 
poultry  three  times  a  week,  and  fish  once  a  week.  Sugar  was  excluded  absolutely, 
saccharin  being  used.  Aspirin  in  three-grain  doses  was  given  after  each  meal, 
with  five  grains  of  bicarbonate  of  soda. 

This  was  the  treatment  for  three  months,  during  which  term  there  was  one 
attack  of  the  asthmatic  bronchitis.  This  responded  to  ipecac,  antipyrin,  and 
sodium  bromid.  Other  than  one  or  two  slight  colds,  the  boj''  has  experienced  no 
trouble  during  the  past  winter.  He  has  lost  but  little  time  at  school.  At  the  end 
of  seven  months  he,  had  gained  seven  pounds  in  weight. 

The  bicarbonate  and  aspirin  were  given  continuously  for  three  months.  Since 
then  they  have  been  given  alternately,  each  for  five  days,  i.  e.,  3  grains  of  aspirin 
three  times  daily  for  five  days,  then  5  grains  of  bicarbonate  of  soda  twice  daily  for 
five  days. 

Cases  Due  to  Direct  Irritation. — In  this  class  belong  comparatively 
few,  notably  those  in  which  the  paroxysm  occurs  independent  of  bron- 
chitis, but  as  a  result  of  direct  irritation  from  the  pollen  of  plants  or  the 
odors  of  animals  or  flowers,  the  irritant  producing  a  condition  known  as 
"hay-fever,"  as  well  as  the  associated  asthmatic  condition.  Hay-fever 
is  rarely  seen  in  children  under  five  years  of  age. 

After  several  attacks  of  asthma  associated  with  bronchitis,  what  is 
sometimes  called  a  true  asthma  results;  i.  e.,  through  the  direct  irrita- 
tion, as  just  mentioned,  or  through  the  peculiar  susceptibility  to  odors, 
such  as  those  from  cats  or  horses,  or  otherwise  reflexly  because  of  the 
presence  of  abnormalities  in  the  upper  respiratory  tract,  the  habit 
becomes  once  established  and  thereafter  but  very  little  irritation  appears 
necessary  to  precipitate  an  attack.  While  these  seizures  may  occur 
without  clinical  bronchitis,  in  not  one  of  them  will  the  bronchi  be  found 
normal,  and  the  intolerance  for  the  intense  carbohydrates  is  as  great 
in  the  cases  in  which  clinical  bronchitis  is  in  evidence. 

Treatment. — The  management  of  bronchial  asthma  consists  in  care 
during  the  attack,  and  the  interval  treatment,  the  latter  being  by  far  the 
more  important.  In  infants  and  young  "runabouts"  with  this  type  of 
trouble  there  is  usually  considerable  bronchitis,  and  this  requires  our 
attention.  I  have  found,  in  addition  to  the  usual  laxatives,— calomel 
or  castor  oil, — that  a  combination  of  syrup  of  ipecac,  antipyrin,  and 
bromid  of  soda  gives  the  most  prompt  results  as  far  as  internal  medica- 
tion is  concerned.  For  a  child  six  months  of  age  the  following  prescrip- 
tion has  been  found  useful: 

I^     Syrupi  ipecacuanha} gtt.  xviij 

Antipyrinse gr-  vj 

Sodii  bromidi gr.  xviij 

Syrupi  rubi  idaei 3  v 

Aquse q.  s.  ad  5ij 

M.  Sig. — One  teaspoonful  every  two  hours — six  doses  in  twenty-four 
hours. 

For  a  child  one  year  of  age : 

I^     Syrupi  ipecacuanhse gtt.  xxiv 

Antipyrinse gr.  xij 

Sodii  bromidi gr.  xxiv 

Syrupi  rubi  idsei 5v 

Aqu« q.  s.  ad  Sij 

M.  Sig. — One  teaspoonful  at  two-hour  intervals — six  doses  in  twenty- 
four  hours. 


ACUTE   SPASMODIC  BRONCHITIS    (BRONCHIAL  ASTHMA)       319 

For  a  child  from  two  to  three  years  of  age : 

I^    Syrupi  ipecacuanhse gtt.  xxxvj 

Antipyringe gr.  xviij 

Sodii  bromidi gr.  xxxvj 

Syrupi  rubi  idaei 3  v 

Aquse q.  s.  ad  gii 

M.  Sig. — One  teaspoonful  in  water  at  two-hour  intervals — six  doses  in 
twenty-four  hours. 

In  addition,  the  child  will  often  be  greatly  relieved  by  stimulant 
inhalations,  as  described  under  Spasmodic  Croup  (p.  287).  If  the  con- 
dition is  urgent,  the  inhalations  may  be  given  for  thirty  minutes  with 
thirty  minutes'  rest. 

Mustard,  in  the  proportion  of  one  part  of  mustard  to  two  parts  of 
flour  (p.  312),  so  applied  as  to  envelop  the  entire  thorax,  will  often  re- 
lieve the  spasm  sufficiently  to  reduce  the  respirations  from  10  to  20  a 
minute.  The  mustard  should  remain  on  long  enough  to  redden  the 
skin,  and  should  not  be  repeated  oftener  than  once  in  four  hours. 

The  cold-air  treatment  in  bronchial  asthma  is  contraindicated, 
regardless  of  the  age  of  the  patient.  Warm,  moist  air  at  from  68°  to 
70°F.  is  best.  A  sudden  blast  of  cold  air  may  be  sufficient  to  increase 
the  severity  of  the  paroxysms  to  a  marked  degree.  Ventilation,  how- 
ever, is  a  necessity  in  these  cases.  The  best  means  of  obtaining  it  is 
by  the  use  of  two  rooms,  one  of  which  may  be  aired  while  the  other  is 
occupied.  Before  the  child  is  changed  to  the  aired  room,  its  tempera- 
ture should  be  raised  to  that  of  the  other. 

In  older  children  after  the  fifth  year  the  bronchial  spasm  may  be 
considerable,  and  more  active  measures  may  be  required  to  furnish 
temporary  relief.  Here  the  methods  usually  employed  for  the  same  pur- 
pose in  adults  may  be  brought  into  use.  A  few  whiffs  of  chloroform 
will  often  be  effective.  Fumes  of  nitrate  of  potash  paper  will  sometimes 
be  of  service.  At  this  age,  also,  a  combination  of  antipyrin  and  bromid 
of  soda  may  be  brought  into  use.  For  a  child  from  five  to  ten  years  of 
age  3  grains  of  antipyrin  with  from  6  to  10  grains  of  bromid  of  soda, 
repeated  in  two  hours,  will  often  obtain  a  cessation  of  the  paroxysm. 
As  soon  as  the  spasm  subsides  the  sedatives  should  be  discontinued. 
I  have  never  found  it  necessary  to  give  morphin  hypodermatically  or 
otherwise  in  these  cases.  In  a  very  severe  case,  in  a  girl  eight  years  of 
age,  a  combination  of  antipyrin  and  codein  in  full  dosage  was  required 
to  control  the  paroxysms.  She  was  given  ^/^  grain  of  codein  and  4 
grains  of  antipyrin  at  two-hour  intervals  until  three  doses  had  been 
given. 

In  the  urgent  cases  La  Fetra  advises  the  use  of  adrenalin  hypo- 
dermically.  Five  minims  of  a  1 :  1000  solution  is  given  to  a  child  from 
two  to  six  years  of  age.  A  diet  with  low  fat  formula,  not  over  2  per 
cent.,  should  also  be  used. 

Before  instituting  interval  treatment  all  growths  in  the  rhino- 
pharynx  should  be  removed,  and  such  abnormalities  as  hypertrophies 
or  deformities  should  be  corrected,  and  the  child  given  a  suitable 
living  regime. 


320  THE    PRACTICE    OF    PEDIATRICS 

Interval  Treatment. — For  the  bottle-fed  this  consists  in  reduction  of 
the  sugar  to  one-half  the  amount  suitable  for  the  age,  and  the  use  of  1 
grain  of  bicarbonate  of  soda  for  each  ounce  of  the  milk  food  given. 
The  bowels  must  be  kept  properly  open,  although  constipation  or  in- 
testinal toxemia  has  never  appeared  to  me  to  be  an  important  factor  in 
asthmatic  children. 

The  interval  treatment  for  older  children  is  most  important,  for  by 
it  we  are  able  to  postpone  the  attacks.  These  cases,  as  I  have  indi- 
cated, are  usual  in  hthemic  subjects,  and  the  scheme  of  management 
followed  out  is  the  same  as  for  rheumatism,  chorea,  recurrent  bronchi- 
tis, and  cyclic  vomiting.  Sugar  is  reduced  to  a  minimum,  and  red  meat 
is  given  not  oftener  than  every  second  day,  and  then  only  in  moderate 
amounts.  The  child's  proteid  nutrition  is  maintained  by  the  use  of  a 
high-proteid  cereal,  such  as  oatmeal,  and  purees  of  dried  peas,  beans, 
and  lentils.  The  eating  of  green  vegetables  is  encouraged.  Food 
between  meals  is  forbidden.  Fruits  are  used  in  moderation  and  an 
active  outdoor  life  is  encouraged.  At  bedtime  the  child  is  given  a 
brine  bath  (p.  780),  followed  by  a  vigorous  dry  rub.  The  mother  or 
attendant  is  instructed  that  one  bowel  evacuation  daily  must  be  in- 
sured. The  medication  consists  of  bicarbonate  of  soda,  from  5  to  10 
grains  a  day  for  five  days,  alternating  with  the  salicylate  of  soda 
(wintergreen)  in  doses  of  from  3  to  5  grains  three  times  a  day.  This  is 
continued  for  a  month  or  two  until  its  effect  in  preventing  a  recurrence 
is  noted.  If  the  salicylate  of  soda  disturbs  the  digestion,  the  same 
quantity  of  aspirin  may  be  given.  The  further  continuation  of  the 
medication  depends  upon  the  effect  already  produced.  Usually  in  two 
months  the  saHcylate  may  be  given  in  smaller  doses.  Interrupted 
medication,  however,  should  be  continued  for  several  months.  When 
my  cases  with  a  bad  family  history  have  been  relieved,  I  continue  the 
diet  permanently,  giving  the  medication  for  but  five  or  ten  days  and 
then  omitting  it  for  sixty  or  eighty  days,  then  giving  it  again  for  a  short 
time,  and  continuing  thus  as  long  as  may  be  thought  best  for  the 
individual. 

PNEUMONIA 

Pneumonia  is  an  infective  process,  due  to  bacterial  invasion,  seen 
with  the  greatest  frequency  in  the  young.  The  influence  of  cold,  which 
is  that  of  shock,  producing  a  lowered  resistance,  temporarily  makes  the 
individual  unusually  susceptible  to  the  infecting  agencies,  which  are 
ever  present.  On  account  of  the  different  ways  in  which  these  infect- 
ing agents  manifest  themselves  in  the  lungs,  two  types  grossly  are  pro- 
duced— broncho-  or  catarrhal  'pneumonia,  and  lobar  or  fibrinous 
pneumonia. 

Lobar  Pneumonia 

Lobar  pneumonia  is  an  acute  infection  of  the  lungs,  primary  in 
character.  It  may  occur  at  any  age.  My  youngest  patient  was  three 
days  old.  Until  the  second  year  this  type  occurs  less  frequently  than 
the  catarrhal  form. 


PNEUMONIA  321 

Etiology. — ^The  influence  of  cold  is  to  produce  a  lowered  resistance. 
Exposure  may  therefore  play  a  part.  The  disease  occurs  with  greatest 
frequency  during  the  winter  and  spring  months. 

Bacterial  Etiology. — The  specific  etiologic  factor  in  the  production  of 
lobar  pneumonia  is  the  pneumococcus  of  Frankel  (Diplococcus  pneu- 
moniae; Micrococcus  lanceolatus) .  The  experimental  evidence  needed 
to  prove  this  fact  has  recently  been  supphed  by  Lamar  and  Meltzer 
(Journal  of  Experimental  Medicine,  February,  1912),  who  showed  that 
intrabronchial  injection  of  pure  cultures  of  Diplococcus  pneumoniae  in 
dogs  produced  pneumonia  of  the  lobar  type  only,  corresponding  both 
grossly  and  microscopically  to  that  lesion  as  found  in  human  beings. 

The  pneumococci  are  found  in  large  numbers  in  the  sputum,  but 
they  invade  the  blood-stream  in  only  about  13  per  cent,  of  the  cases, 
according  to  the  studies  of  Otten  (Jahrbuch  fiir  Kinderheilkunde, 
1909,  Ixix)  and  Churchill  (Transactions  Amer.  Pediatric  Society,  1910), 
a  much  smaller  proportion  than  is  found  in  adults.  Moreover,  about 
half  of  the  cases  with  positive  blood-cultures  recovered. 

In  some  cases  the  .disease  is  caused  by  the  pneumobacillus  of 
Friedlander. 

Predisposition. — ^Lobar  pneumonia  in  the  young  is  not  a  disease  of 
the  weak.  This  type  of  child  is  the  subject  of  bronchopneumonia. 
It  is  usually  the  strong  and  vigorous  child  who  develops  lobar 
pneumonia. 

Pathology. — The  most  apparent  effects  of  the  disease  are  those  pro- 
duced in  the  pulmonary  tissue,  where  there  is  an  exudative  inflamma- 
tion which  progresses  through  four  well-recognized  stages,  to  which  are 
applied  the  terms — (1)  Congestion;  (2)  red  hepatization;  (3)  gray 
hepatization,  and  (4)  resolution.  These  stages  are  not  always  clearly 
defined;  and  not  infrequently,  at  postmortem,  neighboring  portions 
of  a  lung  simultaneously  present  the  appearances  characteristic  of  two 
or  more  stages  of  the  same  inflammation.  Congestion,  consolidation, 
and  resolution  have,  however,  a  very  constant  order  of  occurrence, 
and  this  is  well  understood  when  one  considers  the  exudative  nature  of 
the  inflammatory  process. 

In  the  primary  stage  of  congestion  the  involved  portion  of  the  lung 
is  the  seat  of  active  hyperemia  and  edema,  and  becomes  darker  in  color 
and  acquires  increased  consistence.  The  alveolar  capillaries  are  tur- 
gid, and  the  epithelial  cells  lining  the  air-spaces  are  swollen.  In  the 
stage  of  red  hepatization  a  well-marked  exudation  into  the  alveolar 
spaces  ensues.  The  exudate  consists  chiefly  of  fibrin,  red  blood-cells, 
leukocytes,  and  desquamated  epithelial  cells.  The  involved  lung 
structure  thus  becomes  practically  solid  and  roughly  resembles  liver. 
The  pleurisy,  the  swelling  and  heaviness  and  the  packing  of  the  alveoli 
are  all  most  marked  during  the  red  stage.  During  the  stage  of  gray 
hepatization  the  alveoli  become  choked  with  additional  exudate,  which 
consists  chiefly  of  leukocytes,  the  blood-vessels  undergo  compression, 
and  the  lung  mass  becomes  swollen  and  heavy  and  assumes  a  gray 
appearance.  The  pleura  shares  in  the  inflammation  and  at  this  period 
21 


322  THE    PRACTICE    OF    PEDIATRICS 

is  coated  with  more  or  less  fibrinous  exudate.  The  stage  of  resolution 
marks  the  change  by  which  the  air-cells  are  relieved  of  their  burden  and 
the  normal  circulation  is  restored.  This  process  is  essentially  one  of 
autolysis,  involving  disintegration  of  the  fibrin  meshes  in  the  exudate 
and  degeneration  of  the  masses  of  leukocytes  and  desquamated  epithe- 
Hal  cells.  Large  phagocytic  cells  engulf  the  degenerating  leukocytes 
as  well  as  all  other  granular  particles  and  carry  them  away  in  the 
lymph  stream.     Much  of  the  liquefied  exudate  is  coughed  up  directly. 

Eventually,  the  normal  lung  structure  is  restored  except  in  those 
instances  in  which  the  occurrence  of  interstitial  exudate  has  facilitated 
the  development  of  abscess  or  gangrene,  or  the  usual  dry  pleurisy  has 
been  superseded  by  inflammation  of  the  purulent  type — empj^ema. 

In  cases  of  typical  lobar  pneumonia  the  pneumococcus  present  in 
the  circulating  blood  may  give  rise  to  localized  abscesses  or  such  fatal 
complications  as  peritonitis  and  meningitis. 

Localizations  of  the  Lesions. — Orth's  figures  for  the  localization  of 
lobar  pneumonia  are — 

52  per  cent,  for  the  right  side. 
33  per  cent,  for  the  left  side. 
15  per  cent,  for  both  sides. 

In  217  cases  (Koplik)  the  right  lung  was  involved  in  124  and  the 
left  in  93;  the  upper  right  lobe  in  74,  the  upper  left  in  35,  and  the  upper 
lobe  of  either  lung  in  109  cases,  as  against  100  cases  for  the  lower  lobes. 
Mason*  in  an  interesting  Roentgen  ray  study  of  the  lungs  in  lobar 
pneumonia  has  demonstrated  that,  in  the  silent  pneumonia  usually 
called  central  pneumonia,  the  lesion  is  not  central  but  peripheral  and 
that  voice  and  breath  sounds  are  only  present  when  there  is  evenly 
developed  involvement  extending  from  the  pleural  surface  to  the 
hilum,  supplying  a  medium  which  carries  the  sound  from  the  trachea 
and  large  bronchi. 

As  a  rule,  but  a  portion  of  one  lobe  is  affected.  An  entire  lobe  may 
be  involved,  but  never,  in  my  experience,  has  there  been  found  a  com- 
plete consolidation  of  an  entire  lung.  In  double  pneumonia  a  portion 
of  one  or  more  lobes  in  each  lung  will  be  involved. 

Symptoms. — The  onset  of  the  disease  is  sudden,  with  fever  and 
rapid  respiration,  which  may  be  found  ranging  from  40  to  60.  There 
may  be  cough.  The  temperature  is  variable — over  102°  and  under 
105°F.  The  pulse  is  rapid — 130  to  160 — and  there  is  considerable 
prostration.  These  are  the  only  symptoms  distinctly  indicative  of 
lobar  pneumonia. 

Vomiting,  convulsions,  stupor,  and  chill,  to  which  much  attention 
is  given  by  writers,  may  and  do  occur  with  many  other  diseases,  and 
may  and  do  occur  in  some  cases  of  pneumonia;  thus,  in  my  own  cases 
convulsions  have  ushered  in  the  disease  in  2  per  cent. ;  vomiting  in  less 
than  10  per  cent.;  chill  in  about  5  per  cent.  Loss  of  appetite,  coated 
tongue,  and  drowsiness  are,  of  course,  noted,  and  these  are  all  present 
in  dozens  of  ailments. 

*  Am.  Journal  Diseases  of  Children,  vol.  xii,  pp.  188-189. 


PNEUMONIA 


323 


The  prostration  Is  most  marked  for  the  first  forty-eight  hours. 
After  this  time  the  organism  appears  to  adjust  itself  to  the  changes 
induced  by  the  infection.  During  the  first  or  the  second  day  of  iUness 
the  temperature  becomes  estabhshed  at  a  high  point, — 103°  to  105°F., 
— where  it  remains,  usually  with  slight  variation  in  a  recovery  case, 
until  the  crisis.  This  steady  high  range  of  temperature  (see  Fig.  41) 
is  not  always  followed  out  by  the  disease.  The  fever  may  fluctuate 
considerably.  In  an  eight  months'  old  child  the  temperature  was  that 
of  a  typical  malaria,  99°F.  in  the  morning,  104°  to  105°F.  in  the  late 
afternoon.  The  crisis  occurred  on  the  eighth  day,  and  the  child  was 
promptly  well.  Thorough  examination  from  every  standpoint  failed 
to  show  other  than  a  lobar  pneumonia. 

The  respiration  per  minute  depends  upon  the  amount  of  lung 
involved,  the  virulence  of  the  infection,  and  the  age  of  the  patient.     In 


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children  under  two  years  of  age,  from  60  to  80  respirations  per  minute 
are  not  at  all  unusual.  In  older  children  the  respiration  is  less  rapid, 
often  not  exceeding  60  per  minute.  The  pulse  in  young  children  is  in 
like  manner  more  accelerated — a  range  from  150  to  180  is  not  unusual, 
while  in  children  after  the  third  year  the  rate  may  not  be  above  160. 

Duration  of  the  Attack. — The  duration  is  variable.  In  the  event  of 
mild  infection,  probably  associated  with  good  resistance,  I  have  had 
these  patients  make  the  crisis  on  the  third  day,  even  before  the 
physical  signs  were  positive.  Such  cases  are  by  some  authors  said  to 
represent  the  abortive  type. 

In  the  average  recovery  case  the  crisis  occurs  from  the  fifth  to  the 
ninth  day.  A  crisis  delayed  beyond  the  ninth  day  means  a  very 
serious  infection  and  a  very  grave  prognosis.     I  have  had  recovery 


324  THE    PRACTICE    OF    PEDIATRICS 

cases  in  which  the  crisis  did  not  occur  until  the  eleventh  day.  In  one 
instance  the  crisis  transpired  in  the  thirteenth;  and  in  another,  the 
fifteenth  day. 

Unfavorable  Symptoms. — The  most  unfavorable  symptom  in  lobar 
pneumonia  is  a  low  temperature  in  the  presence  of  the  other  character- 
istic signs — rapidity  of  respiration,  rapid  pulse,  and  prostration. 

Illustrative  Case.^-I  was  called  by  a  practitioner  in  a  New  York  suburb  to  see  a 
case  of  pneumonia  that  disturbed  him  greatly,  although  it  was  impossible  to  make 
the  parents  understand  that  the  child  was  severely  ill.  There  was  no  elevation  of 
the  temperature — in  fact,  it  was  slightly  subnormal.  The  child,  who  was  ten 
months  old  and  had  been  previously  healthy,  showed  marked  pallor  and  prostra- 
tion not  unlike  that  presented  by  an  acute  gastro-intestinal  intoxication  case, 
such  as  is  frequently  seen  in  summer.  The  respiration  was  about  40  and  the  pulse 
was  rapid  and  weak.  There  was  nothing  to  account  for  the  illness  other  than  a 
frank  consolidation  of  the  right  lower  lobe.  I  made  a  fatal  prognosis,  recognizing 
the  probability  of  death  in  a  few  hours.  The  child  died  twelve  hours  after  my 
visit. 

In  this  case  the  child  was  overwhelmed  by  the  pneumococcus  infection,  so  that 
fever  or  any  reaction  was  impossible. 

Cases  of  this  kind  in  vigorous  children  are  rare.  In  athreptics  and 
those  older  children  who  suffer  from  malnutrition  or  who  develop 
pneumonia  after  a  previous  exhausting  disease  the  low  temperature 
range— 100°  to  102°F.— is  not  at  all  unusual.  With  it  will  often  be 
associated  petechial  skin  eruptions.  In  such  instances  the  prognosis 
is  most  unfavorable. 

Tympanites. — The  development  of  marked  abdominal  distention 
is  a  symptom  of  grave  import,  indicating  a  high  grade  of  toxemia. 
Further,  the  distention  interferes  not  a  little,  mechanically,  with  the 
already  embarrassed  respiration. 

Vomiting  and  diarrhea  are  usually  occasioned  by  improper  feeding. 
Uncorrected,  they  add  to  the  dangers  of  the  patient. 

Stupor  and  delirium  are  cerebral  evidences  of  the  systemic  toxemia, 
and  while  they  indicate  a  severe  infection,  their  presence  is  more  con- 
fusing in  a  diagnostic  sense  than  an  indication  of  danger  to  the  patient. 
The  symptoms  are  more  active,  particularly  the  temperature  manifes- 
tation, when  the  right  apex  is  involved.  Such  a  localization,  however, 
has  no  influence  on  the  prognosis. 

Delayed  Crisis. — Every  day  after  the  ninth,  without  the  critical 
drop,  adds  to  the  danger  of  the  patient. 

Lobar  pneumonia  is  rarely  fatal  before  the  ninth  day.  Deaths, 
of  course,  occur  earlier,  due  to  the  severity  of  the  infection,  but  this  is 
very  exceptional. 

Among  eight  fatal  cases  at  the  New  York  Infant  Asylum  in  a  six 
months'  service,  two  died  on  the  eighth  day,  two  on  the  ninth,  two  on 
the  twelfth,  and  one  on  the  twenty-first  day  of  the  disease.  In  the 
cases  of  long  duration  we  have  to  deal  with  a  condition  in  which  the 
individual  is  not  able  to  manufacture  sufficient  antitoxin  to  destroy 
the  infecting  agent  or  agents,  and  the  question  naturally  arises,  will  he 
be  able  to  do  so? 

Complications. — The  advent  of  a  complication  adds  a  more  serious 
aspect  to  the  disease.     A  complication  may  appear  at  any  time  during 


PNEUMONIA  325 

an  attack,  and  change  what  appears  to  be  a  favorable  case  into  one  of 
the  greatest  gravity. 

The  comphcations  that  have  occurred  under  my  observations  are 
as  follows:  myocarditis,  pericarditis,  pneumococcus-meningitis,  pneu- 
mococcus-peritonitis,  empyema,  peri-arthritis,  otitis,  pulmonary  ab- 
scess, and  pulmonary  gangrene. 

Myocarditis. — In  very  severe  infections  in  which  the  temperature 
has  been  high,  a  decided  irregularity  of  the  heart  action  develops. 
There  may  be  no  cyanosis  or  other  indication  of  general  heart  failure. 
The  first  sound  will  be  weak  and  incomplete. 

Pericarditis. — Fluid,  serous  or  purulent,  is  more  often  discovered  at 
the  autopsy  than  recognized  during. the  illness,  and  more  common  in 
left-sided  empyema.  I  have  seen  cases  postmortem  which  showed  the 
pericardial  sac  filled  with  pus  and  fibrin,  and  the  heart  surrounded  with 
the  latter  so  as  to  be  scarcely  recognized,  although  no  cardiac  sign  had 
been  present  during  life,  other  than  that  both  sounds  were  defective. 

Meningitis  of  pneumococcous  origin  (p.  550)  is  not  at  all  unusual 
among  hospital  and  asylum  patients.  An  invasion  of  the  meninges 
by  the  pneumococcus  produces  characteristic  symptoms  (p.  550)  quite 
apart  from  the  usual  manifestations  of  pneumonia,  so  that  recognition 
of  this  complication  is  readily  made.  Further,  when  the  meninges  are 
attacked,  the  resulting  symptoms  are  very  active.  At  once  there  is 
slow,  irregular  respiration,  slow,  irregular  pulse,  stupor  from  which  the 
child  may  not  be  aroused,  and  change  in  the  pupils. 

Peritonitis. — Persistent  distention  of  the  abdomen,  with  evident 
pain  on  pressure,  and  obstinate  constipation  are  indications  of  acute 
peritonitis.     In  my  hands  these  cases — five  in  all — have  all  been  fatal. 

Empyema  (p.  353)  may  develop  during  the  pneumonia,  in  which 
case  the  chief  manifestation  will  be  a  change  in  the  physicial  signs — the 
bronchial  breathing  and  bronchial  voice  changing  suddenly  to  weak, 
distant  bronchial  sounds,  associated  with  flatness  on  percussion. 

Empyema,  however,  is  more  apt  to  follow  a  day  or  two  after  the 
crisis  than  to  occur  during  the  active  stage  of  the  disease.  It  is  a  com- 
plication that  I  have  seen  in  a  large  number  of  cases  in  different  stages 
of  the  disease,  and  the  possibiUty  of  its  development  should  never  be 
forgotten. 

Peri-arthritis  will  be  made  evident  by  pain  and  swelling  of  a  joint, 
most  frequently  the  shoulder  or  elbow. 

Otitis  is  often  overlooked  because  of  the  absence  of  pain  to  locate  the 
trouble.  It  often  passes  unrecognized  until  a  rupture  of  the  drum 
occurs,  the  fever  being  accounted  for  by  the  lung  disease. 

In  every  disease  of  infectious  origin  the  ears  should  be  subjected  to 
a  daily  otoscopic  examination. 

Acidosis  in  Lobar  Pneumonia. — A  child  eighteen  months  of  age 
developed  fever,  prostration  and  rapid  respirations,  the  typical 
hyperpnea  of  acidosis,  active  deep  urgent  breathing,  in  marked  contrast 
to  the  usual  quiet  superficial  sighing,  though  rapid,  respirations  of  lobar 
pneumonia.     The  child  showed  acetone  +  +  +  in  the  urine  and  the 


326  THE    PEACTICE    OF    PEDIATRICS 

acetone  breath  was  very  noticeable.  The  chest  signs  were  sufficient 
for  a  diagnosis  of  pneumonia,  but  the  child  died  from  acidosis. 

Prognosis. — The  prognosis  in  lobar  pneumonia  in  private  cases 
depends  considerably  upon  whether  the  patient  is  under  private  care 
in  a  sensible  family,  or  subject  to  ignorant  surroundings.  If  the  phy- 
sician may  have  the  right  support  the  mortality  is  very  low — from  2  to 
3  per  cent.  Among  the  ignorant  and  careless  it  will  be  higher — from  5 
to  10  per  cent. — approaching  the  mortality  in  hospitals  and  children's 
institutions.  The  high  mortality  in  children's  hospitals  is  due  more  to 
the  wretched  condition  in  which  the  patient  arrives  than  to  peculiarly 
severe  features  of  the  disease.  In  infant  asylums  and  children's  insti- 
tutional homes  a  lack  of  resistance  to  disease  is  the  rule,  and  pneu- 
monia affords  no  exception. 

Diagnosis. — The  diagnosis  in  infants  and  young  children  is  sur- 
rounded with  few  difficulties.  •  The  sudden  onset  of  illness,  with  high 
fever,  rapid  respiration,  dilatation  of  the  alee  nasi,  expiratory  grunt, 
and  rapid  heart  action,  are  objective  signs  of  real  significance. 

Consolidation  of  the  Lungs. — This  sign  makes  the  diagnosis  positive. 
The  time  of  its  appearance,  however,  is  subject  to  considerable  varia- 
tion. It  may  be  present  during  the  first  twenty-four  hours,  and  I  have 
seen  it  repeatedly  delayed  to  the  fourth  day.  Rarely  it  will  appear  as 
late  as  the  fifth  day.  In  one  case,  showing  very  active  symptoms 
otherwise,  consolidation  was  not  apparent  until  the  seventh  day.  On 
the  day  the  consolidation  appeared  crisis  occurred.  Cases  of  this  type 
may  go  through  the  entire  course  of  the  disease  and  never  show 
definite  consolidation.  Such  pneumonia  was  formerly  referred  to  as 
"central."  Mason  of  New  York  has  demonstrated  by  Roentgen  ray 
studies  that  these  cases  are  really  marginal  pneumonia.  There  is  no 
doubt  but  that  a  pneumococcous  infection  of  the  lung  may  exist  for 
several  days  and  run  its  entire  course  without  the  process  ever  going 
on  to  consolidation,  demonstrable  by  our  usual  means  of  examination. 
We  know  that  this  is  possible  in  the  two  or  three  day  cases  represent- 
ing clinically  the  so-called  abortive  type. 

The  Physical  Signs. — Auscultation. — As  already  indicated,  auscul- 
tation may  never  reveal  a  sign  of  the  disease  other  than  harsh  or  sono- 
rous breathing.  As  a  rule,  the  infiltration  of  the  air-cells  will  develop 
sufficiently  from  the  second  to  the  fourth  day  to  produce  bronchial 
breathing  and  bronchophony. 

Over  the  consolidated  area  fine  pleuritic  friction  rales  will  usually 
be  heard  at  the  height  of  inspiration  when  the  consolidation  makes  its 
appearance.  In  practically  every  case  of  lobar  pneumonia  the  pleura 
over  the  consolidated  surface  will  be  found  dry,  injected,  and  often 
showing  a  very  fine  exudation. 

Percussion. — Percussion  will  show  dulness,  depending  in  degree  and 
extent  upon  the  nature  and  distribution  of  the  lesion.  Absolute  dulness 
will  be  present  only  over  the  consolidated  area. 

The  chief  value  of  percussion  is  in  differentiating  the  presence  of 


PNEUMONIA  327 

fluid  from  extensive  fibrinous  exudation,  a  condition  sometimes  desig- 
nated as  pleuropneumonia. 

Palpation. — Palpation  is  of  little  value  in  children,  and  reveals 
nothing  that  may  not  be  learned  through  auscultation  and  percussion. 

Vocal  Fremitus. — In  diagnosing  considerable  exudations  of  fluid  in 
the  pleural  cavity,  and  pneumothorax,  the  absence  of  vocal  fremitus 
may  furnish  corroborative  evidence. 

Differential  Diagnosis. — ^Lobar  pneumonia  is  to  be  differentiated 
from  pneumonia  of  the  catarrhal  type,  from  acute  pleurisy  with  massive 
output  of  fluid,  and  from  similar  cases  in  which  the  fluid  is  less  in 
amount.  The  differentiation  between  the  lobar  and  bronchopneu- 
monia will  be  found  on  p.  336. 

Pleuritic  Effusion. — When  there  is  a  fluid,  pleuritic  exudate  sufl5- 
cient  to  fill  the  entire  cavity,  with  the  fluid  under  pressure  over  a  com- 
pressed and  consolidated  lung,  signs  will  be  transmitted  to  the  chest- 
wall,  closely  resembling  the  signs  of  frank  consolidation.  Thus  there 
will  be  bronchial  breathing  and  bronchophony  of  a  very  intense  char- 
acter over  the  entire  involved  side  anteriorly  and  posteriorly,  at  both 
the  apex  and  the  base.  Repeatedly  in  consultation  I  have  found  these 
signs  interpreted  by  the  attending  physician  as  meaning  a  complete 
consolidation  of  the  lung.  It  is  to  be  remembered  that  a  lung  is  never 
entirely  consolidated  in  acute  pneumonia.  Furthermore,  in  the 
presence  of  a  massive  fluid  exudate  percussion  will  elicit  flatness  over 
the  entire  surface.  When  the  process  is  located  on  the  left  side,  the 
heart  displacement  indicates  the  presence  of  fluid  in  the  pleural 
cavity. 

In  cases  of  effusion,  finally,  there  is  an  absence  of  friction-sounds  and 
likewise  of  rales.  When  doubt  exists,  exploratory  puncture  should 
alwaj'^s  be  made.  Fluid  in  lesser  amounts  is  indicated  by  diminished 
respiratory  sounds,  localized  flatness,  the  absence  of  mucous  or  pleuritic 
rales,  and  displacement  of  the  heart  if  the  exudation  is  in  sufficient 
amount.  Only  in  cases  in  which  the  pleural  cavity  is  absolutely  filled 
with  fluid  do  we  find  the  voice  and  respiratory  signs  of  frank  lobar 
pneumonia. 

Blood-findings  in  Lobar  Pneumonia. — (See  p.  397.) 

Treatment. — ^Lobar  pneumonia  runs  a  limited  course,  with  a  strong 
tendency  to  recovery.  It  is  a  disease  which  children  bear  well  under 
proper  management.  There  is.  no  specific  treatment,  and  our  efforts 
in  restoring  the  patient  to  health  are  supportive  only. 

When  a  child  is  stricken  with  lobar  pneumonia,  we  know  that  his 
physical  strength  is  to  be  severely  tested,  and  our  first  effort  should 
be  to  place  him  in  such  a  position  that  he  may  to  the  best  advantage 
cope  with  the  enemy.  In  order  to  do  this  every  detail  of  his  daily 
life  should  so  be  arranged  as  to  assist  all  the  organs  of  the  body  most 
favorably  to  combat  the  changed  conditions  produced  by  disease. 
Telling  the  mother  what  to  do  for  the  fever  and  writing  a  prescription 
for  a  cough  mixture  is  a  most  careless  method,  worthy  of  the  prescrib- 
ing apothecary  rather  than  a  physician.     A  proper  regime  must  be 


328  THE  PRACTICE  OF  PEDIATRICS 

established  as  soon  as  the  child  becomes  ill.  The  bowel  function,  the 
room-temperature,  ventilation,  and  sleep,  as  well  as  special  medication, 
are  all  to  be  considered.  The  child  must  be  kept  as  comfortable  as  the 
conditions  allow,  and  his  comfort  demands  the  avoidance  of  everything 
causing  restlessness  or  irritability,  which  throws  more  work  upon  the 
heart  and  lessens  the  patient's  resistance  to  the  disease. 

Cold  Air, — In  strong  robust  children  the  cold  air  treatment  is  to 
be  advised.  These  patients  unquestionably  do  better  with  the  win- 
dows wide  open  day  and  night.  In  such  an  atmosphere  the  respiration 
is  slower,  the  heart  action  is  stronger,  and  the  patients  are  much  more 
comfortable,  sleep  better,  and  make  a  more  satisfactory  convalescence. 
A  woolen  hood  and  suitable  woolen  clothing  should  be  worn. 

The  Sick-room. — In  cases  or  in  families  in  which  the  cold  air  treat- 
ment is  not  practicable,  the  temperature  of  the  room  should  be  kept  at 
61°  to  65°F.  both  day  and  night.  Wide  fluctuations  in  the  temperature 
should  not  be  allowed.  A  large  room,  if  at  hand,  should  always  be 
selected,  and  there  must  always  be  direct  communication  with  the 
open  air  by  an  open  window.  The  child  should  be  kept  in  the  crib, 
and  not  held  on  the  lap  of  the  mother  or  nurse. 

Quiet  should  be  maintained  in  the  sick-room,  only  those  in  atten- 
dance upon  the  patient  being  admitted.  A  sick-room  is  no  place  for 
visitors  and  curious  persons.  Their  presence  annoys  the  child  and 
takes  away  a  certain  number  of  strength  units,  which  may  determine 
the  outcome  of  the  case.  The  advantages  of  the  cold  room  or  roof 
treatment  in  this  respect  are  obvious. 

The  Clothing. — The  clothing  should  be  the  usual  night-clothing. 
I  have  long  since  discarded  the  oiled-silk  jacket  or  any  special  form  of 
covering.  The  oiled-silk  jacket  or  a  jacket  made  of  cotton  wadding  is 
very  easy  to  put  on,  but  very  difficult  to  take  off  with  safety;  further, 
it  has  a  tendency  to  elevate  the  temperature  of  the  patient,  it  makes 
him  uncomfortable,  particularly  during  convalescence,  and  prevents 
the  free  action  of  the  skin.  These  objections,  with  the  fact  that  there 
is  no  rational  argument  for  such  wrappings,  are  sufficient  to  condemn 
them. 

The  Bowels. — There  should  be  a  standing  order  with  the  nurse  or 
mother  for  an  enema  to  be  given  if  the  bowels  do  not  move  once  in 
twenty-four  hours.  One-half  to  one  grain  of  calomel  in  doses  of  J^ 
grain  every  hour  is  usually  of  considerable  service.  In  a  case  in  which 
there  is  very  high  fever  I  often  order  this  dosage  repeated  every  three 
or  four  days. 

Counter  irritation. — Counterirritation  of  the  skin  is  of  little  service 
in  lobar  pneumonia.  Early  in  the  attack,  when  there  is  pain,  a  mus- 
tard plaster, — one-third  mustard  and  two-thirds  flour, — mixed  to  a 
paste,  spread  on  cheese-cloth,  and  placed  over  the  involved  area  for 
a  few  moments,  will  give  signal  relief  and  may  be  repeated  at  intervals 
of  from  four  to  five  hours.  This  form  of  counterirritation  is  also  use- 
ful in  convalescence  in  delicate  children  when  the  lung  clears  slowly, 
and  examination  reveals  feeble  breathing  and  many  mucous  rales.     In 


PNEUMONIA  329 

such  cases  two  or  three  applications  daily  until  the  lung  clears  will 
suffice.  Each  application  should  be  maintained  until  the  skin  is  well 
reddened.  If  reddening  does  not  occur  within  ten  minutes,  the  mix- 
ture of  mustard  and  flour  should  be  made  stronger — one-half  mustard 
to  one-half  flour.  In  a  few  cases  of  delayed  resolution  two  dry  cups 
daily,  applied  directly  over  the  involved  areas,  have  been  of  much 
service. 

The  Diet.— See  Diet  in  Illness,  p.  109. 

Management  of  Pyrexia. — Whether  or  not  antipyretic  measures  are 
to  be  used,  and  the  nature  of  the  antipyretic  to  be  advised,  depends 
upon  the  case  and  the  family  possibilities  relating  to  care  and  nursing. 
One  child  will  bear  a  temperature  without  inconvenience  which  would 
seriously  compromise  the  chances  of  recovery  of  another,  so  that  the 
thermometer  is  not  a  sufficient  guide  unless  the  effect  of  the  fever  upon 
the  patient  be  considered.  Some  children  will  be  delirious  and  restless 
and  will  need  antipyretic  treatment  when  the  fever  is  at  103°F.  A 
temperature  of  104°F.  rarely  needs  interference.  A  rise  of  1°F. 
usually  means  an  increase  of  20  to  30  heart-beats  per  minute.  In 
lobar  pneumonia  I  prefer  that  the  temperature  should  not  go  above 
105°F,,  even  if  at  the  time  the  child  shows  but  little  inconvenience. 
Such  a  temperature  means  an  unnecessary  increase  in  the  amount  of 
work  required  of  the  heart,  which  itself  demands  relief  in  such  an 
emergency. 

Hydrotherapy. — -Cold  water,  intelligently  applied,  is  the  best  means 
of  reducing  fever.  The  water  may  be  used  either  in  the  form  of  a 
sponge-bath  or  a  cool  pack.  The  sponge-bath  (p.  780),  repeated  at 
intervals  of  from  two  to  four  hours,  suffices  in  a  few  cases  in  which  the 
temperature  is  readily  influenced.  As  a  rule,  the  cool  pack  (p.  777) 
will  be  required,  especially  if  the  fever  is  particularly  high.  The 
sponge-bath,  while  not  controlling  the  fever  as  well  as  does  the  pack, 
possesses  the  advantage  of  safety  even  when  administered  by  the  most 
ignorant.  The  procedure  really  amounts  to  nothing  more  than  spong- 
ing the  entire  body  with  cool  water  or  alcohol  and  water.  The  cool 
pack  requires  a  trained  nurse  or  an  intelligent  mother,  either  of  whom 
should  be  instructed  by  the  physician  as  to  its  use.  When  cool  water 
is  properly  applied,  and  the  packs  or  baths  agree,  prompt  improve- 
ment in  the  immediate  symptoms  follows.  The  child,  previously  rest- 
less and  perhaps  delirious,  falls  into  a  quiet  sleep ;  the  temperature  falls 
two  or  three  degrees,  the  pulse  becomes  slower  and  fuller,  and  the  res- 
piration less  frequent.  I  have  never  seen  a  carefully  given  pack  or 
bath  do  harm  to  a  child.  In  fact,  the  water  is  most  grateful  to  the 
patients,  who,  when  old  enough,  often  ask  to  have  the  towel  made 
cooler  when  it  becomes  warm  and  dry  from  the  heat  of  the  body. 

Heart  Stimulants. — A  child  must  never  be  given  a  heart  stimulant 
simply  because  he  has  pneumonia.  Heart  stimulation  is  usuallj-  em- 
ployed too  early  in  the  attack.  Only  when  the  pulse  shows  signs  of 
weakness,  great  rapidity,  irregularity,  or  reduced  volume,  has  the 
time  arrived  for  stimulation.     For  a  very  rapid  pulse,  i.  e.,  over  150, 


330  THE    PRACTICE    OF    PEDIATRICS 

tincture  of  strophanthus  has  answered  better  in  my  hands  than  any 
other  form  of  stimulation.  For  a  child  from  six  months  to  one  year 
old,  I  order  one  drop  every  two  hours — at  least  six  doses  in  twenty- 
four  hours;  for  a  child  from  one  to  three  years  old,  one  or  two  drops 
at  intervals  of  two  hours — at  least  six  doses  in  twenty-four  hours;  for 
a  child  of  three  years  or  over,  two  or  three  drops  at  intervals  of  two 
hours — at  least  six  doses  in  twenty-four  hours.  If  the  case  is  a  very 
serious  one,  the  strophanthus  may  be  given  every  two  hours  during 
the  entire  twenty-four,  although  if  the  conditions  permit,  it  is  better 
to  disturb  the  patient  as  infrequently  as  possible  during  the  night. 

When  the  pulse  is  irregular  and  intermittent,  with  reduced  volume, 
strychnin  is  the  remedy.  To  a  child  from  six  months  to  a  year  old 
y'i  00  grain  is  to  be  given  every  three  hours — six  doses  in  twenty-four 
hours;  from  the  first  to  the  second  year,  3^^oo  grain  at  three-hour  in- 
tervals— six  doses  in  twenty-four  hours;  after  the  second  year,  3^50 
grain  may  be  given  at  intervals  of  three  or  four  hours — six  doses  in 
twenty-four  hours.  Children  who  are  under  strychnin  medication 
should  be  carefully  watched  for  signs  of  the  physiologic  effects  of  the 
drug,  the  first  symptoms  being  an  unusual  susceptibility  to  sudden 
noise  and  a  slight  fibrillary  twitching  of  the  muscles  of  the  face  and  the 
backs  of  the  hands.  Instructions  should  be  given,  when  these  symp- 
toms appear,  to  discontinue  the  drug  until  the  next  visit  of  the 
physician.  I  have  repeatedly  noticed  these  signs  of  the  physiologic 
effects  of  the  administration  of  strychnin,  and  they  need  cause  no 
anxiety.  They  are  actually  necessary  in  order  to  get  the  full  benefit 
of  the  drug.  However,  it  is  only  in  the  most  severe  cases  that  this 
drug  should  be  pushed  to  such  an  extent. 

When  the  circulation  of  the  skin  is  deficient,  involving  coldness  of 
the  extremities  and  cyanosis,  indicated  by  blueness  of  the  finger-nails 
and  lips,  nitroglycerin  is  indicated.  To  a  child  under  one  year  of  age, 
3^00  grain  may  be  given  at  intervals  of  two  or  three  hours — six  doses 
in  twenty-four  hours;  to  a  child  from  one  to  three  years  of  age,  Hoo 
grain  at  three-hour  intervals — -six  doses  in  twenty-four  hours;  after 
the  third  year,  3^150  grain  at  intervals  of  two  or  three  hours — six  doses 
in  twenty-four  hours.  Nitroglycerin,  if  given  in  large  doses,  produces 
headache,  of  which  older  children  will  complain,  while  nurslings  will 
show  their  discomfort  by  restlessness  and  crying. 

Caffein  sodiosalicylate  is  also  very  useful  in  cases  of  this  nature, 
and  may  with  advantage  be  employed  with  the  strychnin.  The  dos- 
age for  a  child  from  six  months  to  one  year  is  }'2  grain.  Camphor  in 
the  form  of  the  oil  of  camphor  is  useful  hypodermatically  in  the  con- 
dition just  described.  It  may  be  given  in  one  to  two  grain  doses  and 
repeated  in  one  to  two  hours.  In  collapse,  3^ooo  solution  of  adrenalin 
hypodermatically,  administered  in  dosage  of  from  three  to  five  drops, 
is  of  much  use. 

Digitalis  is  rarely  used  as  a  heart  stimulant  for  young  children 
It  disturbs  the  stomach  and  meets  conditions  much  less  satisfactorily 
than  the  remedies  mentioned.     The  ammonium  preparations  are  not 


PNEUMONIA  331 

employed,  because  their  administration,  even  for  a  short  period,  in- 
variably interferes  with  nutrition  by  diminishing  the  digestive  capacity. 

Alcohol  is  often  prescribed  too  early.  Many  of  my  cases  of  pneu- 
monia in  children  pass  through  an  entire  attack  without  one  drop  of 
alcohol.  Alcohol  in  any  form  should  be  avoided  early  in  the  disease. 
Later,  when  the  case  is  doing  badly,  when  the  strychnin  and  strophan- 
thus,  alone  or  in  combination,  fail,  the  alcohol  may  be  given,  and  then 
it  may  be  a  life-saving  means.  It  is  indicated  at  this  time  because  it 
sustains  the  patient  when  regular  food  assimilation  is  impossible,  and 
at  the  same  time  stimulates  the  heart.  Under  one  year  of  age  I  give 
from  8  to  30  drops  of  brandy,  at  two-hour  intervals;  from  one  to  two 
years  of  age,  15  drops  to  1  dram  at  two-hour  intervals;  over  two  years, 
1  to  2  drams  at  two-hour  intervals.  Patients  who  show  profound  sep- 
sis will  require  and  consume  an  enormous  quantity  of  alcohol  without 
showing  the  slightest  intoxicating  effect.  During  my  term  as  resident 
physician  of  the  New  York  Infant  Asylum  a  child  fourteen  months  of 
age,  ill  with  diphtheria,  was  given  4  ounces  of  brandy  in  twenty-four 
hours  without  showing  signs  of  stupor  or  intoxication. 

Hypodermic  Stimulation. — The  use  of  hypodermic  stimulation  in 
•children  is  to  be  advised  in  an  emergency,  or  when  the  stomach  becomes 
intolerant,  or  when  it  becomes  evident  that  drugs  administered  by 
mouth  are  not  absorbed.  If  the  dietetic  means  suggested  are  carried 
out,  and  if  disturbing  drugs,  such  as  the  ammonium  salts,  heavy 
syrups,  etc.,  are  omitted,  there  will  rarely  be  any  occasion  to  resort  to 
hypodermic  stimulation.  When  indicated,  the  doses  suggested  for  the 
stomach  may  be  given  hypodermically,  with  the  exception  that  alcohol 
should  not  thus  be  given  in  quantities  greater  than  one-half  dram  of 
brandy  or  whisky  at  one  time. 

Gavage. — Cases  are  encountered  in  which,  for  a  time,  on  account  of 
the  profound  toxemia,  no  food  or  medicine  will  be  taken.  In  such  in- 
stances the  giving  of  stimulants  and  predigested  food  by  means  of 
gavage  (p.  790),  will  be  of  material  assistance.  The  milk  used  should 
be  completely  peptonized,  and  to  it  whisky,  brandy,  and  stimulating 
drugs  may  be  added.  The  forced  feeding  should  not  be  used  oftener 
than  once  in  four  hours,  and  preferably  only  once  in  six  hours.  When 
thus  given,  the  individual  doses  of  the  stimulants  should  be  increased. 

The  Murphy  drip  method  of  using  a  normal  salt  solution  is  of 
service  in  cases  in  which  feeding  difficulties  are  insurmountable. 

Specific  Medication. — There  is  no  drug  known  which  will  cut  short 
or  abort  an  attack  of  lobar  pneumonia.  Mercury  in  the  form  of  large 
doses  of  calomel,  quinin,  salicylate  of  soda,  and  other  drugs  have  no 
specific  action. 

As  previously  stated,  our  efforts  must  be  directed  toward  a  conser- 
vation of  the  strength  of  the  patient  by  placing  him  in  the  best  position 
to  cope  with  the  disease.  This  management,  combined  with  careful 
medication  to  meet  special  requirements  as  they  arise,  constitutes  our 
treatment  of  lobar  pneumonia,  and  has  given  us  a  death-rate  of  only  2 
per  cent,  in  children  under  two  years  of  age.     During  convalescence 


332  THE    PRACTICE    OF    PEDIATRICS 

great  care  is  needed  in  permitting  the  child  to  resume  his  usual  habits 
of  life,  for  in  the  matters  of  both  food  and  exercise  we  must  make 
haste  slowly. 

Bronchopneumonia  (Catarrhal  Pneumonia) 

Catarrhal  pneumonia  is  preeminently  a  disease  of  infancy.  On  ac- 
count of  its  large  mortality,  and  because  of  its  frequent  occurrence  as 
a  complication  of  almost  every  other  disease  of  infancy,  it  is  one  of  the 
most  formidable  ailments  which  we  are  called  upon  to  treat.  The  dis- 
ease is  usually  described  as  primary  or  secondary.  Among  the  several 
hundred  cases  which  have  come  under  my  observation,  comparatively 
few — less  than  5  per  cent. — have  been  primary.  Those  described  as 
primary  usually  follow  a  bronchitis — often  a  neglected  bronchitis. 
The  severity  of  the  disease  varies  considerably,  depending  on  the  age 
and  condition  of  the  child,  the  nature  of  the  infection,  and  the  amount 
of  lung  involved.  It  is  most  fatal  when  associated  with  diphtheria, 
measles,  and  pertussis. 

Catarrhal  pneumonia  demands  our  most  careful  attention,  not 
only  on  account  of  the  delicate  organs  attacked,  but  because,  unlike 
lobar  pneumonia,  scarlet  fever,  typhoid  fever,  and  many  other  diseases 
of  early  life,  this  disease  has  no  self-limitation,  no  cycle.  While  in 
treating  the  other  diseases  mentioned  we  are  required  only  to  assist  a 
patient  through  the  various  stages,  in  case  of  catarrhal  pneumonia  we 
must  do  more,  for  here  a  cure  is  demanded.  We  are  not  aided  by  a 
tendency  to  time  limitation. 

Etiology. — The  cause  predisposing  to  bronchopneumonia  is  the 
tender  age  of  the  patient,  who,  on  this  account,  offers  little  resistance 
to  the  infection.  Children  debilitated  from  any  cause  are  predisposed 
for  a  like  reason.  Whooping-cough  and  measles  more  than  any  other 
diseases  predispose  to  bronchopneumonia.  In  a  large  number  of  fatal 
cases  of  marasmus  and  malnutrition,  bronchopneumonia  is  the  termi- 
nating illness. 

Bacteriologic  Etiology. — The  bacteriologic  cause  of  bronchopneu- 
monia is  not  a  specific  entity.  There  are  a  number  of  microorganisms 
which  may  cause  the  disease,  and  in  over  60  per  cent,  of  the  cases  there 
is  a  mixed  infection.  This  is  true  even  in  the  primary  cases.  The 
Diplococcus  pneumonise  (Frankel)  is  the  bacterium  most  frequently 
present,  but  it  is  found  in  pure  culture  only  about  one-fourth  as  often  as 
in  combination  with  other  organisms.  The  streptococcus  comes  next 
in  order  of  frequency — three  times  more  often  in  combination  than  in 
pure  culture.  The  Staphylococcus  aureus  may  be  present  alone,  but  is 
far  oftener  found  with  the  pneumococcus  or  the  streptococcus.  The 
bacillus  of  Friedlander,  either  in  pure  culture  or  in  mixed  infection,  is  a 
rare  cause  of  bronchopneumonia  in  children.  Since  bronchopneu- 
monia may  be  secondary  to  a  variety  of  diseases,  the  causative  organ- 
ism of  the  primary  condition  in  a  given  case  may  be  found  in  the  pul- 
monary lesion.  Thus  B.  diphtherise,  B.  influenzae,  the  Bordet-Gengou 
bacillus  of  pertussis,  B.  typhosus,  B.  pestis,  B.  anthracis,  B.  pyocya- 


BRONCHOPNEUMONIA    (CATARRHAL    PNEUMONIA)  333 

neus,  or  the  meningococcus  may  be  found  associated  with  one  or  more 
of  the  pyogenic  cocci.  B.  coH  communis  is  a  possible  though  very  rare 
factor  in  this  disease. 

Age. — A  great  majority  of  the  cases  occur  in  children  under  two 
years  of  age.  Over  one-half  of  these  patients  are  under  one  year  of  age. 
After  the  third  year  bronchopneumonia  is  unusual  except  as  a  compli- 
cation of  measles  or  pertussis. 

Pathology. — Bronchopneumonia  almost  invariably  occurs  as  a 
sequel  to  acute  bronchitis  or  one  of  the  infectious  diseases  involving 
inflammation  in  the  upper  respiratory  tract.  Ordinarily  the  process 
begins  as  an  inflammation  of  the  terminal  bronchioles,  "capillary 
bronchitis,"  and  by  extension  involves  the  air-vesicles  and  acquires  the 
character  of  a  true  pneumonia.  Bronchopneumonia  is,  as  a  rule, 
bilateral,  and  only  exceptionally  involves  a  single  lobe  of  one  lung. 
The  disease  usually  produces  inflammation  of  the  pleura.  The  affected 
lung  acquires  increased  weight  and  the  regions  most  involved  acquire  a 
firmer  consistence  and  a  deeper  red  or  a  grayer  color  than  normal,  de- 
pending on  the  stage  of  the  inflammation,  which  at  the  outset  occasions 
intense  congestion  without  much  leucocytic  exudation.  On  section, 
the  affected  portions  typically  appear  mottled,  owing  to  the  contrast 
apparent  between  the  masses  of  solid  and  aerated  lobules. 

Microscopic  examination  reveals  an  inflammation  of  the  bronchioles 
and  of  the  walls  of  the  air-vesicles  immediately  surrounding.  There 
is  not  only  an  exudate  in  the  air-vesicles,  but  also  an  interstitial  exu- 
date. In  the  bronchopneumonic  exudate,  the  cells  are  more  predomi- 
nantly mononuclear,  and  the  amount  of  fibrin  is  less  than  in  the  exu- 
date of  lobar  pneumonia.  The  lesions  are  distributed  throughout  the 
lungs  in  patches,  but  show  a  tendency  to  become  conglomerate  as  the 
disease  advances.  When  the  inflammation  subsides  the  exudate  is 
removed,  as  at  the  termination  of  lobar  pneumonia  by  mechanical 
processes  and  by  the  agency  of  autolysis.  The  interstitial  infiltration 
characteristic  of  bronchopneumonia  is  responsible  for  the  occurrence 
of  its  more  important  sequelae,  none  of  which  commonly  follow  lobar 
pneumonia.  These  are  chronic  bronchitis,  spasmodic  asthma,  emphy- 
sema, and  chronic  interstitial  pneumonia.  Pleurisy,  when  it  occurs  in 
children,  irrespective  of  the  character  of  complicating  pneumonia,  is  of 
a  productive  type. 

Physical  Signs. — Auscultation — The  signs  elicited  by  auscultation 
depend  upon  the  stage  of  the  disease  and  the  degree  of  lung  involvement. 

The  Respiratory  Murmur. — The  respiratory  murmur  may  be  weak- 
ened over  certain  areas,  or  it  may  be  scarcely  discernible.  Usually  an 
involved  area  will  be  found  to  shade  off  gradually  to  the  normal. 
There  may  be  several  of  these  areas. 

Rales.' — Areas  of  localized  fine  mucous  rales  are  very  suggestive  of 
bronchopneumonia.  The  fine  crepitant  rale  is  often  heard  over  the 
consolidated  area.  In  cases  in  which  there  is  a  considerable  distribu- 
tion of  the  pneumonic  process  there  will  be  a  wide  distribution  of  rales, 
with  sibilant  and  fine,  moist,  mucous  rales  predominating.     The  rales 


334  THE    PRACTICE    OF    PEDIATRICS 

are  only  evenly  distributed  in  cases  of  the  acute  congestive  type.  In 
these  cases  they  are  heard  both  on  inspiration  and  on  expiration,  and 
are  of  a  very  fine,  crepitant  quality. 

Percussion. — In  the  very  acute  cases  in  which  the  engorgement 
interferes  with  the  entrance  of  air  into  the  lungs  extra  resonance  or 
tympanitic  dulness  may  be  found.  In  other  cases  the  percussion-note 
serves  as  an  indication  of  the  degree  and  extent  of  lung  involvement. 
The  signs  vary  from  normal  to  those  of  complete  dulness. 

Palpation. — "Whatever  may  be  elicited  by  palpation  is  better  dem- 
onstrated by  auscultation  and  percussion. 

Symptoms. — The  symptoms  are  most  variable,  depending  upon  the 
age  of  the  patient,  the  severity  of  the  infection,  the  extent  of  lung  in- 
volved, and  the  associated  illness  and  complications. 

In  nearly  all  cases  in  which  the  process  in  the  lungs  is  active  there 
are  three  symptoms  which  rarely  fail  to  be  present:  accelerated  respira- 
tion, fever,  and  cough.  The  symptoms  are  only  exceptionally  urgent 
at  the  onset.  Usually  there  is  bronchitis  for  a  few  days,  without  high 
fever  or  rapidity  of  the  respiration.  Then,  apparently  on  the  eve  of 
improvement,  the  temperature  ranges  higher,  the  respirations  per  min- 
ute increase,  and  the  child  shows  prostration. 

Examination  of  the  lungs  at  this  time  may  reveal  localized  fine  rales, 
usually  posterior,  in  one  or  both  lungs.  As  the  urgency  of  the  symp- 
toms increases  the  temperature  ranges  from  101°  to  104°F.,  subject  to 
considerable  variations,  and  reaches  the  normal  by  lysis. 

The  respiration  is  from  40  to  60.  The  pulse-rate  is  rarely  under 
140.  The  usual  range  is  from  140  to  160.  Upon  the  appearance  of 
these  symptoms  the  chest  signs  become  more  marked.  Localized 
areas  of  fine  rales  appear  in  different  portions.  There  are  also  areas  in 
which  the  respiratory  murmur  is  very  weak.  Consolidation  usually 
develops  sufficient  to  produce  bronchophony  and  bronchial  breathing. 

Duration. — The  duration  of  a  case  of  this  type  in  the  event  of 
recovery  is  rarely  less  than  three  weeks.  Often  a  much  longer  time 
elapses  before  the  chest  will  be  free.  In  the  fatal  cases  there  is  an 
increase  in  the  volume  of  lung  involved,  shown  by  the  physical  signs. 
The  heart  action  becomes  feeble,  and  death  takes  place  from  exhaustion 
or  supervening  complication. 

Special  Types  of  Bronchopneumonia. — In  the  description  of  a  dis- 
ease with  as  wide  possibilities  as  bronchopneumonia,  a  large  number 
of  types  could  be  laid  down  which  would  add  confusion  to  the  subject. 
As  in  most  diseases  due  to  infections,  death  may  take  place  very  early 
or  the  infection  may  be  so  mild  as  to  pass  unrecognized.  When  we 
take  into  consideration  the  age  of  the  patient,  the  varieties  of  micro- 
organisms that  may  be  operative,  and  the  amount  of  lung  tissue  that 
may  be  involved,  we  can  readily  appreciate  that  the  disease  is  subject 
to  many  and  varied  manifestations.  Among  these  possibilities  there 
is  one  feature  that  should  be  emphasized.  Consolidation  of  the  lung 
is  not  necessary  for  a  right  diagnosis  of  pneumonia.  Elevation  of  the 
temperature,  respiration  over  40,  dilatation  of  the  alae  nasi,  and  cough^ 


BRONCHOPNEUMONIA    (CATARRHAL    PNEUMONIA)  335 


together  with  mucous  rales,  usually  definitely  localized,  are  sufficient 
for  a  diagnosis  of  bronchopneumonia. 

Cases  of  the  More  Active  Type. — Bronchopneumonia  may  be  so 
severe  as  to  be  fatal  in  a  few  hours.  At  the  New  York  Infant  Asylum 
I  saw  several  such  cases  which  later  came  to  autopsy.  The  condition 
is  usually  diagnosed  as  acute  capillary  bronchitis.  In  such  patients 
the  onset  is  sudden,  with  high  fever,  103°  to  lOG^F.,  rapid,  labored 
respiration,  60  to  80,  rapid  pulse,  160  to  180,  and  cyanosis.  There  is 
marked  prostration  from  the  onset.  The  child  is  toxic  and  rapidly 
becomes  unconscious.  Auscultation  shows  a  very  marked  increase  in 
respiratory  murmur  and  a  few  fine  rales.  The  patients  present 
evidence  of  a  sudden  invasion  of  pneumococci  of  a  virulent  type. 


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Fig.  42. — Temperature  chart.     Bronchopneumonia. 

Doubtless  cases  of  this  type  are  never  correctly  diagnosed.  In  two 
such  cases  seen  by  me  a  positive  diagnosis  could  not  have  been  made 
but  for  the  autopsy.  On  account  of  the  urgency  of  the  symptoms  and 
the  cerebral  manifestations  of  stupor  and  sometimes  convulsions,  the 
cases  are  looked  upon  as  those  of  cerebrospinal  meningitis,  malignant 
scarlet  fever,  suppressed  measles,  or  acute  toxemia  from  intestinal 
sources. 

Postmortem  examination  shows  an  intense  pulmonary  congestion. 
A  free  incision  in  the  lung  removed  immediately  after  death  will  be  fol- 
lowed by  a  profuse  flow  of  dark  blood.  Excepting  the  congestion  and 
the  presence  of  the  pneumococcus,  there  are  few  findings  to  indicate  the 
nature  of  the  disease,  the  process  having  been  too  active  and  too 
rapidly  fatal  for  the  development  of  the  lesions. 

Several  years  ago  I  was  called  to  perform  an  autopsy  on  a  six-year- 
old  boy  who  had  died  after  a  two  days'  illness,  the  nature  of  which 


336  THE    PRACTICE    OF    PEDIATRICS 

could  not  be  agreed  upon  by  the  medical  attendants,  none  of  whom  had 
suspected  pneumonia.  The  autopsy  findings  were  those  of  an  acute 
pneumonia  with  intense  pulmonary  engorgement  and  with  right  heart 
dilatation,  which  corresponded  to  the  clinical  history.  Cases  of  this 
nature  represent  the  extreme  possibilities  of  pneumococcus  infection. 

There  are  other  cases  in  which  the  symptoms  are  urgent  but  less 
pronounced:  The  onset  is  sudden,  with  high  fever,  103°  to  105°F. 
The  respiration  is  rapid,  40  to  60,  rarely  there  is  a  convulsion.  Vomit- 
ing is  usually  present  as  an  early  symptom  and  occurs  but  once. 
Except  in  the  nature  of  the  onset,  the  course  in  these  cases  does  not 
vary  materially  from  the  usual  type  first  described.  The  temperature 
range,  physical  signs,  duration  and  prognosis  are  much  the  same  as  in 
the  cases  of  gradual  onset. 

Bronchopneumonia  Following  Other  Diseases. — When  broncho- 
pneumonia follows  pertussis,  influenza,  measles,  or  diphtheria,  it 
shows  no  variations  from  its  usual  course,  but  finds  a  lessened  resist- 
ance because  of  what  has  gone  before.  The  prognosis  is  therefore 
correspondingly  less  favorable,  the  disease  being  particularly  fatal  with 
or  after  pertussis,  measles,  and  diphtheria. 

Complications. — ^Among  the  complications,  otitis  is  probably  the 
most  frequent.  Empyema  occurs  in  a  small  proportion  of  the  cases. 
The  same  is  true  of  pericarditis,  meningitis,  arthritis  and  nephritis. 
Emphysema  is  always  present  to  a  slight  degree,  and  except  in  rare 
instances  is  demonstrable  in  autopsies  on  children  dying  with  broncho- 
pneumonia. If  the  illness  has  been  a  long  one,  with  considerable  lung 
involvement,  the  emphysema  may  be  very  extensive. 

Differential  Diagnosis. — Bronchopneumonia  is  to  be  differentiated 
from  acute  bronchitis  and  lobar  pneumonia.  When  the  respiration 
is  persistently  above  40  per  minute  and  the  temperature  persistently 
above  102°F.,  uncomplicated  bronchitis  does  not  exist,  and  pneumonic 
involvement  of  the  lung  is  highly  probable. 

If  there  is  an  associated  bronchial  spasm  increasing  the  respiration, 
a  differential  diagnosis  is  more  difficult  and  sometimes  impossible,  as 
pneumonia  may  exist  with  a  low  temperature  range. 

In  lobar  pneumonia  the  well-defined  consolidated  area  in  the  lung, 
the  absence  of  bronchial  catarrh,  and  the  usually  persistent  high 
temperature  (see  Fig.  41)  are  sufficient  to  establish  the  type  of  the 
infection. 

The  age  of  the  patient  may  be  of  assistance.  Lobar  pneumonia  is 
uncommon  under  two  years  of  age,  and  the  great  majority  of  the  cases 
of  bronchopneumonia  occur  before  this  period. 

Prognosis. — Bronchopneumonia  is  a  disease  of  high  mortality.  In 
children's  hospitals  and  institutions  a  considerable  portion  of  the  total 
mortality  is  due  to  bronchopneumonia.  It  is  safe  to  say  that  from  25 
to  50  per  cent,  of  the  hospital  cases  are  fatal.  This,  of  course,  includes 
all  cases  of  bronchopneumonia,  those  complicating  whooping-cough, 
measles,  scarlet  fever,  and  diphtheria,  as  well  as  the  terminal  cases  that 
occur  late  with  many  other  ailments  of  infants  and  children.     The 


BRONCHOPNEUMONIA    (CATARRHAL    PNEUMONIA)  337 

age  and  previous  condition  of  the  patient  have  a  decided  influence 
upon  the  mortality.  The  younger  and  feebler  the  patient,  the  less  is 
the  chance  for  recovery. 

Rachitis,  malnutrition,  and  marasmus  are  indirectly  accountable 
for  many  deaths. 

Treatment.— Every  child  at  the  commencement  of  an  illness  has  a 
definite  resistance  to  disease.  In  catarrhal  pneumonia,  for  the  reasons 
just  given,  it  must  be  our  effort  to  preserve  every  strength  unit  which 
the  child  possesses.  An  immense  amount  of  vitality  in  sick  children  is 
wasted  because  of  irritability,  restlessness,  and  loss  of  sleep.  One  of 
the  first  duties  in  a  given  case  is  not  to  give  this  or  that  drug  or  use  this 
or  that  local  application,  but  to  make  the  child  comfortable — to  put 
him  in  the  best  position  to  withstand  disease.  We  must  establish  and 
maintain  a  high  degree  of  resistance,  and  must  establish  a  sick-room 
regime  which  will  make  this  possible. 

The  Sick-room. — The  value  of  a  constant  supply  of  fresh  air  is  too 
little  appreciated.  In  every  case  there  should  be  a  direct  communica- 
tion between  the  sick-room  and  the  open  air  throughout  the  attack. 
Various  means  of  ventilation  have  been  devised,  of  which  the  window- 
board  (p.  138)  is  the  most  effective,  as  it  separates  the  sash  and  allows 
the  free  entrance  of  a  current  of  air  which  is  directed  upward.  If 
plenty  of  fresh  air  at  a  proper  temperature  were  available  during  the 
early  part  of  the  illness,  there  would  be  much  less  use  for  tanks  of 
oxygen  later. 

An  absolute  necessity  in  a  sick-room  is  a  thermometer.  In 
pneumonia  cases  it  should  never  register  above  70°F.  There  is  a 
marked  tendency  to  coddle,  to  wrap,  and  to  overclothe  these  patients. 
The  patient  requires,  even  during  the  winter,  absolutely  nothing  more 
than  a  medium-weight  flannel  shirt,  a  band,  if  one  is  ordinarily  worn, 
and  the  usual  night-dress.  Some  years  ago  I  discarded  the  oiled-silk 
jacket.  It  is  cumbersome,  it  is  impossible  to  keep  clean,  and  it  over- 
heats the  patient.  An  infant  with  catarrhal  pneumonia,  heavily  clad, 
in  an  un ventilated,  overheated  room,  and  in  close  contact  with  an 
adult  body,  is  tremendously  handicapped.  There  is  but  one  place  for 
a  sick  infant,  and  that  is  in  his  own  roomy  crib. 

Diet. — In  every  illness  with  fever  the  digestive  capacity  is  consider- 
ably reduced.  If  the  usual  milk  diet  is  continued,  we  are  very  liable 
to  have  a  gastro-enteric  infection  added,  often  as  a  serious  complication, 
to  the  existing  disease.  For  the  breast-fed  child  a  drink  of  water 
should  be  ordered  before  the  nursings  and  between  them.  The  nurs- 
ing hours  should  be  the  same  as  in  health,  but  the  time  allowed  for  each 
nursing  should  be  reduced  from  one-third  to  one-half.  For  the  bottle- 
fed  the  milk  strength  should  be  reduced  from  one-third  to  one-half  by 
dilution  with  water,  the  quantity  remaining  the  same.  Children  from 
two  to  four  years  of  age  should  be  restricted  to  a  diet  of  diluted  milk, 
gruels,  and  broths. 

Bowels. — Normal  bowel  function  is  more  necessary  for  the  sick  than 
for  the  well.  There  should  be  at  least  one  stool  in  twenty-four  hours. 
22 


338  THE    PRACTICE    OF    PEDIATRICS 

General  Treatment. — Having  placed  the  child  under  the  best  dietetic 
and  hygienic  conditions,  we  are  in  a  position  to  use  medication  to  a 
much  better  advantage.  But  in  its  use,  and  in  performing  the  various 
offices  for  the  patient,  it  must  be  our  effort  to  disturb  him  as  little  as 
possible.  In  our  anxiety  to  do,  we  are  very  liable  to  overdo,  with  dis- 
astrous results.  If  a  well  child  were  given  syrup  expectorants,  stimu- 
lants, baths,  and  local  applications,  something  being  done  for  him  every 
hour  or  two  in  the  twenty-four,  he  would  have  to  be  strong  to  withstand 
the  treatment.  We  should  treat  our  ill  with  still  greater  consideration. 
The  intervals  between  which  the  child  is  to  be  disturbed  at  night  should 
be  made  as  long  as  possible  by  giving  food,  medicine,  and  local  treat- 
ment at  one  time.  When  possible,  I  always  endeavor  to  make  the 
interval  at  least  three  hours. 

Steam  Inhalations. — Among  the  distinctly  remedial  measures,  aside 
from  those  administered  internally,  steam  inhalations  with  creosote 
deserve  an  important  place.  The  patient  is  placed  in  the  crib,  which 
is  covered  and  draped  with  sheets  so  as  to  make  a  fairly  tight  inclosed 
space.  The  apparatus  necessary  is  an  ordinary  croup  kettle.  Ten 
drops  of  creosote  are  added  to  one  quart  of  water  and  placed 
in  the  kettle.  The  nozzle  of  the  kettle  is  introduced  between 
the  sheets  at  a  safe  distance  from  the  child's  face  and  hands,  the  steam- 
ing being  carried  on  for  thirty  minutes  every  three  hours.  The  sheets 
should  be  parted  slightly  about  every  ten  minutes,  to  allow  a  renewal 
of  the  air.  The  inhalations  are  to  be  given  whether  the  patient  is 
asleep  or  awake.  As  he  improves,  they  may  be  given  less  frequently 
until  normal  respirations  and  the  chest  signs  tell  us  this  treatment  is  no 
longer  required. 

Counterirritants. — The  application  of  counterirritants  to  the  skin 
over  the  thorax  is,  to  my  mind,  of  great  service  in  cases  in  which  there 
is  much  bronchial  catarrh.  This  includes,  of  course,  most  cases.  In 
order  that  a  counterirritant  may  be  of  service,  a  distinct  red  blush  must 
be  produced  on  the  skin.  Turpentine  diluted  with  oil, — one-third 
turpentine  and  two-thirds  oil, — when  briskly  rubbed  on  the  parts  for  a 
few  minutes,  produces  a  fairly  satisfactory  counterirritation.  The  old- 
fashioned  home-made  mustard  plaster  has  also  served  me  well.  Writ- 
ten directions  should  always  be  given  for  the  preparation  of  the  plaster, 
and  the  boundaries  of  the  area  of  the  skin  to  be  covered  should  be  out- 
lined with  a  pencil  on  the  skin's  surface.  If  the  nurse  or  mother  is  told 
merely  to  put  a  mustard  plaster  on  the  chest,  a  plaster  the  size  of  a 
man's  hand  will  usually  be  placed  somewhere  between  the  umbilicus 
and  the  chin.  For  the  first  two  or  three  applications  one  part  of  mus- 
tard to  two  parts  of  flour  is  used.  This  is  moistened  with  warm  water 
and  made  of  the  consistence  of  a  rather  thin  paste,  which  is  then  spread 
upon  cheese-cloth,  old  muslin,  or  linen,  cut  to  the  desired  size.  The 
plaster  is  readily  held  in  position  by  a  bandage  or  any  thin  material 
extending  around  the  chest.  When  the  skin  is  well  reddened — usually 
within  from  five  to  fifteen  minutes, — the  plaster  is  removed  and  vaselin 
or  sweet  oil  is  applied.     I  never  use  a  plaster  oftener  than  once  in  six 


BRONCHOPNEUMONIA    (CATARRHAL    PNEUMONIA)  339 

hours,  and  then  only  in  the  severest  cases.  Ordinarily,  two  or  three 
applications  in  twenty-four  hours  are  sufficient.  If  the  plasters  are 
continued  for  several  days,  in  order  to  avoid  blistering  it  will  be  neces- 
sary to  make  them  much  weaker  after  a  day  or  two — one  part  of  mus- 
tard to  five  or  ten  of  flour.  Counterirritation  is  particularly  effective 
when  used  at  the  commencement  of  an  attack. 

Mustard  Baths. — In  cases  of  sudden  onset  with  high  fever,  rapid 
breathing,  and  cold  extremities,  a  mustard  bath — one  tablespoonful 
of  mustard  to  six  gallons  of  water  at  110°F. — will  often  furnish  marked 
relief  from  the  immediate  symptoms.  The  duration  of  the  bath  should 
be  from  one  to  three  minutes,  and  while  in  the  bath  the  skin  should  be 
subjected  to  active  manipulation  by  hand  rubbing.  Autopsies  on  such 
subjects  show  a  general  congestion  of  the  internal  organs,  with  intense 
congestion  of  the  lungs.  The  bath  may  be  repeated  at  six-hour  inter- 
vals. This  type  of  bronchopneumonia  is  usually  very  rapid  in  its 
development,  the  child  being  relieved  or  dead  within  thirty-six  to 
forty-eight  hours.  By  "relieved"  we  do  not  mean  that  the  child  has 
recovered,  but  that  the  acute,  urgent  symptoms  have  subsided.  In 
my  opinion  only  these  rapid  cases  should  be  considered  primary. 

Drugs. — The  internal  medication  is,  to  a  large  extent,  symptomatic. 
In  any  disease  a  great  deal  of  harm  may  be  done  to  young  children  by 
the  thoughtless  use  of  drugs.  In  catarrhal  pneumonia  it  is  particularly 
necessary  that,  in  our  endeavors  to  assist  the  patient,  we  do  nothing  to 
harm  him,  for  we  are  treating  a  disease  in  which  his  powers  of  resist- 
ance count  for  everything.  In  young  children,  even  in  health,  the 
digestive  functions  are  very  easily  disordered.  In  illness  with  fever, 
with  the  accompanying  nervous  exhaustion,  the  stomach  is  most  easily 
disturbed,  the  child  is  not  properly  nourished,  and  his  powers  of  resist- 
ance are  markedly  diminished. 

Expectorants  must  be  given  with  care,  and  are  better  prescribed 
in  the  form  of  tablets  or  powders.  The  use  of  heavy  syrups  of  wild 
cherry,  tolu,  etc.,  with  large  doses  of  the  ammonium  salts,  only  adds  to 
the  burden  of  the  patient.  For  a  child  one  year  of  age  with  catarrhal 
pneumonia,  Moo  grain  of  tartar  emetic  and  3^^o  grain  of  ipecac  answer 
w6ll  as  an  expectorant.  If  the  cough  is  very  severe  and  persistent,  3^ 
grain  of  Dover's  powder  in  tablet  form,  with  sugar-of-milk  dissolved  in 
at  least  two  teaspoonfuls  of  water,  may  be  given,  preferably  after  feed- 
ing, not  oftener  than  once  in  two  hours.  The  ammonium  salts  so 
generally  used  in  catarrhal  pneumonia  for  routine  treatment  are  badly 
borne  by  the  stomach.  Ammonium  muriate  is  of  some  value  during 
resolution,  but  to  a  child  two  years  old  it  should  not  be  given  in  larger 
doses  than  3^^  grain  well  diluted,  at  two-hour  intervals.  Personally, 
however,  I  rarely  use  it. 

In  the  event  of  high  fever  and  great  restlessness,  which  are  not 
affected  by  sponging,  and  where,  for  any  reason,  rational  bathing  is 
impossible,  a  combination  of  caffein,  Dover's  powder,  and  phenacetin 
may  be  used.  For  a  child  one  year  of  age  I  would  give  3^^  grain  of 
caffein,  3^^  grain  of  Dover's  powder,  and  13^^  grains  of  phenacetin  at 


340  THE    PRACTICE    OF    PEDIATRICS 

about  four-hour  intervals.  In  giving  Dover's  powder  it  is  well  to 
watch  the  bowels,  as  constipation  often  follows  its  use. 

Heart  stimulants  are  usually  necessary,  and  in  their  selection  two 
points  are  to  be  considered — their  effect  on  the  heart  and  their  effect 
on  the  stomach.  But,  first,  what  are  the  indications  for  the  use 
of  heart  stimulants?  Ordinarily,  I  think,  they  are  used  too  early. 
A  heart  stimulant  should  never  be  given  simply  because  a  child  has 
pneumonia  or  diphtheria  or  scarlet  fever,  but  it  should  be  given  in 
pneumonia  or  diphtheria  or  scarlet  fever  as  soon  as  the  heart  needs 
assistance.  Briefly,  there  are  two  conditions  to  guide  us — a  very  rapid 
pulse  and  a  soft,  not  rapid,  pulse,  with  a  tendency  to  irregularity.  In 
a  general  way,  I  believe  that  a  heart  which  is  beating  at  the  rate  of  150 
a  minute  during  quiet  or  sleep,  and  which  is  not  strengthened  by  spong- 
ing or  packs,  needs  assistance.  The  drug  which  has  served  me  best  is 
tincture  of  strophanthus,  which  acts  as  a  direct  stimulant  to  the  heart 
muscle.  The  pulse,  by  its  use,  is  made  stronger,  fuller,  and  less  rapid. 
When  the  heart's  action  shows  a  tendency  to  irregularity,  with  a  soft, 
easily  compressible  pulse,  then  strychnin  is  the  remedy.  Caffein 
sodiosalicylate  in  3'^-grain  doses  every  two  hours  is  also  of  much  use  in 
such  a  condition.  For  a  child  one  year  of  age  one  drop  of  strophanthus 
in  water  may  be  given  every  three  hours,  or  3'^oo  grain  of  strychnin 
every  three  hours,  to  be  increased  to  3-^00  or  even  to  3^oo  grain  every 
three  hours  for  a  few  doses,  if  the  case  is  carefully  watched  for  symp- 
toms of  strychnin  poisoning.  Strophanthus  and  strychnin  possess 
advantages  over  all  other  stimulants  in  that  they  do  their  work  and 
have  no  unpleasant  effect  on  the  stomach,  as  is  the  case  with  alcohol, 
digitalis,  and  the  ammonium  preparations.  If  the  condition  is  very 
urgent,  strophanthus  and  strychnin  may  be  used  in  combination.  I 
rarely  employ  digitalis  because  of  its  tendency  to  interfere  with  diges- 
tion. Alcohol  in  the  form  of  whisky  or  brandy  is  very  rarely  of  great 
service  in  catarrhal  pneumonia.  It  may  stimulate  the  heart,  but  its 
prolonged  use  greatly  upsets  the  stomach.  It  should  be  withheld  until 
late  in  the  disease,  when  other  means  of  stimulation  fail.  Then,  given 
in  large  amounts,  it  may  be  the  means  of  saving  the  patient.  One- 
half  dram  of  whisky  or  brandy,  well  diluted,  may  be  given  every  hour 
or  every  two  hours  to  a  child  one  year  of  age.  However,  the  cases  of 
catarrhal  pneumonia  actually  saved  by  the  use  of  alcohol  are  few  indeed. 
Nitroglycerin,  /^^oo  grain  every  three  hours  for  a  child  one  year  of  age, 
is  of  service  in  cases  where  there  is  marked  cyanosis  with  cold  extremi- 
ties. Its  use  should  be  discontinued  as  soon  as  improvement  in  this 
respect  is  noticed.  The  one  unpleasant  feature  that  I  have  observed 
from  its  administration  is  its  tendency  to  produce  headache  and 
marked  restlessness. 

Hypodermic  Medication. — In  all  urgent  cases  in  which  collapse  is 
threatened,  or  when  stomach  medication  does  not  give  results  desired, 
I  employ  the  hypodermic,  using  the  same  dosage  as  given  by  the 
mouth.  Camphor  may  be  given  in  two-grain  doses  and  repeated 
hourly  if  necessary.     Digitalin,  3^^oo  grain,  may  be  given  and  repeated 


BRONCHOPNEUMONIA    (CATARRHAL    PNEUMONIA)  341 

in  three  or  four  hours.  For  urgent  collapse,  camphor  and  1  :  1009 
solution  of  adrenalin,  3  to  5  minims,  are  our  best  stimulants. 

Baths. — A  sponge-bath  at  95°F.  for  cleansing  purposes  may  be 
given  daily. 

Pyrexia. — What  is  to  be  our  guide  in  dealing  with  the  pyrexia? 
At  what  degree  of  temperature  are  we  to  interfere?  This  depends  to  a 
great  extent  upon  what  is  behind  the  fever  and  the  effect  of  the  fever 
upon  the  individual  patient.  If  a  child  has  a  high  fever  and  is  more 
comfortable  when  it  is  reduced,  if  he  will  digest  his  food  better  and  sleep 
better,  our  duty  is  to  reduce  temperature.  Further,  by  reducing  it 
we  lessen  the  work  of  the  heart,  saving  many  beats  per  minute.  Usu- 
ally, when  the  rectal  temperature  has  a  tendency  to  run  above  104°F., 
interference  is  of  advantage,  and  the  best  means  at  our  command  is  the 
use  of  local  applications  of  water  in  the  form  of  sponge-baths  or  packs. 
If  the  temperature  is  easily  controlled,  a  sponge-bath  will  answer  our 
purpose.  Either  salt  or  alcohol  may  be  added  to  the  water.  Ordina- 
rily, two  teaspoonfuls  of  salt  to  a  quart  of  water,  or  one  part  alcohol  to 
three  parts  water,  is  ample.  Cold  water  thus  used  serves  two  pur- 
poses— it  acts  as  a  sedative  and  it  reduces  the  fever.  Cold  sponging, 
while  not  as  effectual  as  a  bath  or  a  pack,  possesses  the  advantage  of 
being  applicable  even  in  the  hands  of  the  most  unskilled.  For  spong- 
ing, the  child  should  be  stripped  and  covered  with  a  flannel  blanket, 
the  sponging  being  done  under  the  blanket.  In  order  not  to  antagon- 
ize or  frighten  him,  it  is  best  to  begin  with  the  water  at  95°F.  and  gradu- 
ally to  reduce  the  temperature  to  70°  or  75°F.  by  the  addition  of  ice 
or  cold  water.  The  sponging  may  be  continued  from  ten  to  twenty 
minutes,  and  should  not  be  repeated  at  shorter  intervals  than  ninety 
minutes.  After  the  sponging  is  completed  the  skin  should  be  rubbed 
briskly  for  a  few  minutes  with  a  dry  towel.  If  the  temperature  is  not 
readily  controlled  in  this  way,  it  is  best  to  use  other  means,  as  too 
frequent  sponging  exhausts  the  patient.  As  a  means  of  controlling 
the  temperature  in  children,  the  tub-bath  has  not  been  successful  in 
my  hands,  for  the  reason  that  I  have  not  been  able  by  this  means  to 
control  the  fever.  The  exposure,  the  fright,  and  the  necessary  short- 
ness of  the  bath  render  it  very  unsatisfactory. 

By  far  the  best  means  at  our  command  for  controlling  a  continued 
high  fever  is  the  cold  pack  (p.  777).  Properly  applied,  it  is  without  the 
slightest  danger.  A  large  bath-towel  or  any  thick  absorbent  material 
may  be  used,  slits  being  cut  in  one  end  of  the  towel  through  which  the 
arms  may  pass.  The  towel  should  be  folded  over  the  body,  and  should 
extend  from  the  neck  to  the  middle  of  the  thighs,  the  arms  and  the  legs 
from  the  knees  down  remaining  free.  A  hot-water  bag,  carefully 
guarded,  should  be  placed  at  the  feet.  The  towel  is  moistened  with 
water  at  95°F.  It  is  well  to  make  the  pack  warm  at  first,  so  that  the 
child  will  not  be  frightened,  as  shock  will  thus  be  avoided.  I  have 
known  severe  shock  to  occur  when  a  child  with  a  temperature  of  105°F. 
was  put  suddenly  into  a  pack  at  70°F.  In  two  or  three  minutes  the 
towel  is  moistened  with  water  at  85 °F.,  then  at  80°F.     When  80°F.  is 


342  THE    PRACTICE    OF   PEDIATRICS 

reached,  it  is  best  not  to  make  the  water  any  colder  for  half  an  hour,  at 
which  time  the  temperature  of  the  patient  is  taken.  If,  in  the  begin- 
ning, it  is  105°F.  and  at  the  expiration  of  the  half-hour  shows  slight  or 
no  reduction,  the  temperature  of  the  pack  may  be  reduced  to  70°  or 
even  to  60°F.,  by  the  addition  of  cold  water  or  ice,  without  removing 
the  child,  who  is  turned  from  side  to  side  so  that  all  parts  of  the  envelop- 
ing towel  may  be  moistened  with  cool  water.  During  the  first  hours 
in  the  pack  the  temperature  should  be  taken  every  half-hour,  and  when 
it  is  reduced  to  102°F,,  the  child  should  be  removed  and  wrapped  in  a 
warm  blanket.  In  cases  of  sudden  and  persistent  high  fever  the  child 
may  be  kept  in  the  pack  continuously.  We  aim  to  keep  the  tempera- 
ture between  102.5°  and  103. 5°F.  A  fresh  towel  should  be  apphed 
every  three  hours.  An  ice-bag  should  be  kept  at  the  head,  a  hot- water 
bag  at  the  feet,  and  the  patient  should  be  covered  with  a  flannel  blanket 
of  medium  weight.  The  degree  of  cold  necessary  to  control  the  fever 
in  a  given  case  will  soon  be  learned.  I  recently  kept  in  a  pack  for 
seventy-two  hours  a  four-year-old  boy  ill  with  lobar  pneumonia.  In 
this  case  a  pack  at  70°F.  was  necessary  to  keep  the  temperature  at 
104°F.  or  slightly  lower. 

Oxygen. — Oxygen  is  of  immense  service  in  very  severe  cases  with 
much  lung  involvement.  It  may  be  given  continuously  for  one  or  two 
minutes  out  of  every  seven  or  ten.  As  often  given,  for  one  or  two 
minutes  every  half-hour,  it  is  of  little  or  no  service. 

INTERSTITIAL  PNEUMONIA,  INCLUDING  BRONCHIECTASIS 

Interstitial  pneumonia  occurs  in  two  types  of  cases.  After  bron- 
chopneumonia the  interstitial  variety  represents  an  unresolved  pneu- 
monia, and  usually  means  that  the  individual  has  had  more  than  one 
attack.  The  great  majority  of  such  cases  are  seen  in  ill-conditioned 
infants  in  hospitals  and  institutional  homes.  Rarely  is  this  type  seen 
in  older  children.  I  have  seen  but  six  cases  in  children  over  four  years 
of  age. 

The  second  type  represents  the  cases  of  unresolved  pneumonia, 
usually  lobar  pneumonia,  which  have  been  complicated  by  empyema, 
and  in  which  the  empyema  has  not  been  recognized  or  has  been  im- 
properly treated. 

Pathology. — Chronic  interstitial  pneumonia  is  a  productive  inflam- 
mation characterized  by  thickening  of  the  connective-tissue  framework 
of  the  lung.  This  disease  follows  one  or  more  attacks  of  broncho- 
pneumonia or  may  accompany  a  chronic  empyema.  The  process  may 
involve  one  or  more  lobes  of  the  lung,  or  only  a  portion  of  one  lobe. 
The  involved  lung  is  usually  adherent  to  the  chest-wall  by  very  dense 
fibrous  adhesions,  and  is  smaller  than  normal,  firm,  and  grayish  in 
color.  On  section,  the  pleura  and  connective-tissue  septa  are  found  to 
be  greatly  thickened.  The  bronchi  are  often  dilated,  and  may  be  the 
seat  of  purulent  bronchitis. 

Microscopic   examination  shows  that  the  interlobular  septa,  the 


INTERSTITIAL   PNEUMONIA,    INCLUDING  BRONCHIECTASIS       343 

walls  of  the  bronchi  and  blood-vessels,  and  the  alveolar  walls  are  thick- 
ened with  connective  tissue.  As  a  consequence  some  alveoli  may  be 
compressed  and  empty. 

Compensatory  emphysema  is  often  present  in  a  portion  of  the 
unaffected  lung. 

Sjrmptoms. — Not  half  the  symptoms  described  by  writers  exist. 
The  principal  manifestation  is  afforded  by  the  condition  of  the  patient, 
who  is  anemic,  emaciated,  and  fails  to  thrive,  or  improves  but  slowly 
even  under  the  best  surroundings. 

There  may  be  cough  and,  rarely,  fever.  The  respiration  is  acceler- 
ated upon  exertion,  but  otherwise  shows  no  change.  If  there  is  an 
associated  bronchiectasis,  in  older  patients,  there  will  be  mucopurulent 
or  purulent  expectoration. 

A  boy  who  was  under  my  care  for  several  years  expelled  free  ex- 
pectoration about  once  a  day.  There  was  an  interstitial  pneumonia 
involving  the  lower  half  of  the  right  lung,  which  was  the  seat  of  one  or 
more  bronchiectatic  cavities.  The  pus  evidently  collected  periodically 
and  filled  the  cavity,  then  irritation  would  be  excited,  producing  cough 
and  emptying  of  the  cavity. 

Diagnosis. — There  may  be  extensive  retraction  of  the  chest-wall 
or  none  at  all,  depending  on  the  age  of  the  patient;  in  infants  under 
eighteen  months  there  is  rarely  such  retraction. 

Upon  forced  inspiration,  as  in  crying,  it  will  be  noticed  that  the 
chest-wall  over  the  involved  lung  area  fails  to  take  part  in  the  normal 
respiratory  excursion.  In  the  cases  of  older  children  there  are  varying 
degrees  of  retraction,  usually  associated  with  spinal  curvature. 

Auscultation. — The  respiratory  signs  are  subject  to  wide  variations. 
Thus  in  one  case  there  may  be  bronchial  breathing  over  one  diseased 
area  and  entire  absence  of  the  respiratory  murmur  over  another  area. 
Between  these  extremes  in  the  same  case  there  may  be  every  variety 
of  abnormal  respiratory  sounds.  Over  the  uninvolved  lung  the  respira- 
tory murmur  undergoes  pronounced  exaggeration.  If  there  is  a  con- 
siderable bronchiectasis,  signs  of  a  cavity  will  be  indicated  by  amphoric 
breathing. 

Percussion. — Percussion  invariably  shows  localized  dulness  over 
the  diseased  portion  of  the  lung.  One  may  find  all  shades  of  dulness 
to  flatness.  Over  the  free  portion  of  the  lung,  hyperresonance  will  be 
found  because  of  the  emphysema,  which  is  always  present  in  slight  or 
moderate  degree. 

Differential  Diagnosis. — The  question  that  always  arises  in  these 
cases  relates  to  the  possibility  of  tuberculosis.  A  considerable  number, 
particularly  of  the  young,  do  develop  tuberculosis.  An  examination 
of  the  sputum  and  the  von  Pirquet  tuberculosis  test  should  invariably 
be  made.  In  cases  in  young  infants  a  positive  von  Pirquet  reaction 
supplies  reliable  corroborative  evidence.  Repeated  examination  of 
the  bronchial  secretions  (p.  362)  will  reveal  the  tubercle  bacillus  if  it  is 
present.  In  the  cases  of  older  children  examination  of  the  sputum 
quickly  determines  the  diagnosis. 


344  THE    PRACTICE    OF    PEDIATRICS 

Prognosis. — The  prognosis  in  infants  is  very  unfavorable.  If 
tuberculosis  does  not  develop,  intercurrent  diseases,  such  as  the  intes- 
tinal diseases  of  summer,  whooping-cough,  measles,  or  further  acute 
pneumonia,  will  very  likely  terminate  the  case.  Recovery  is  not  im- 
possible, however,  and  I  have  known  infants  to  make  almost  complete 
recoveries  after  the  process  had  existed  for  months.  In  one  case  the 
child's  chest  did  not  begin  to  "clear"  until  after  the  third  month.  In 
recovery  cases  the  interstitial  change  could  not  have  been  at  all  exten- 
sive. In  older  children,  after  the  sixth  year,  recoveries  as  regards  life 
are  the  rule.  Whether  the  case  follows  a  bronchopneumonia  or  a 
pneumonia  with  empyema,  even  with  the  best  results,  there  will  be  left 
a  more  or  less  crippled  lung,  which  does  not  necessarily  compromise 
the  later  well-being  of  the  patient.  Such  patients,  however,  are  more 
Hable  to  tuberculous  infection,  and  this  possibility  is  always  to  be  taken 
into  consideration  in  their  management. 

Bronchiectasis. — Bronchiectasis  is  present  in  a  considerable  num- 
ber of  these  cases,  both  in  the  young  and  older  children.  It  consists  of 
dilatation  of  the  bronchi,  such  dilatation  being  usually  sacculated  or 
cylindric  in  form.  The  lungs  of  a  child  eighteen  months  of  age  who 
died  from  bronchopneumonia  of  three  months'  duration,  with  termi- 
nal sepsis,  presented  several  small  cylindric  dilatations.  One  of  these, 
with  a  capacity  of  six  drams,  was  found  in  the  right  lung.  This  case  is 
similar  to  many  seen  at  autopsy.  In  young  infants  bronchiectasis 
may  be  very  difficult  of  demonstration.  In  the  cases  of  older  patients 
the  expectoration  of  pus  in  a  chronic  pneumonia  is  very  suggestive, 
and  in  such  instances  physical  examination  may  reveal  amphoric 
breathing  and  other  signs  of  cavity. 

Dilatation  of  a  bronchus  may  be  cylindric,  sacculated,  or  spindle- 
shaped.  It  is  accompanied  either  by  atrophy  or  by  hypertrophy  of  the 
mucosa  and  of  the  entire  bronchial  wall.  Dilated  bronchi  contain 
thick  mucous  or  purulent  secretion,  often  in  very  large  amount.  The 
secretion  may  be  blood-stained,  due  to  rupture  of  some  of  the  very 
numerous  blood-vessels  in  the  hypertrophied  mucosa.  Pressure  of  the 
dilated  bronchi  often  causes  collapse  of  the  pulmonary  alveoli  surround- 
ing them.  The  walls  of  neighboring  bronchi  may  fuse,  forming  larger 
cavities. 

Treatment. — The  treatment  of  interstitial  pneumonia  is  not  par- 
ticularly brilliant  in  results.  There  is  always  the  hope  that  the  inter- 
stitial process  dependent  on  cicatricial  change  is  not  extensive,  for  this 
feature  determines  in  no  little  degree  the  outcome  of  the  case.  When 
resolution  takes  place,  it  occurs  always  from  the  periphery  toward  the 
center  of  the  diseased  part.  The  involved  area  becomes  smaller  and 
smaller  and  disappears,  or,  more  frequently,  as  the  ultimate  outcome, 
an  area  of  weakly  vesicular  breathing  remains  to  mark  the  site  where 
the  disease  was  most  active. 

Little  can  be  accomplished  by  the  use  of  drugs  except  to  improve 
the  nutrition  of  the  patient.  Children  with  this  unfortunate  pulmo- 
nary disease  should  take  up  their  permanent  residence  in  a  dry  climate. 


PNEUMOTHORAX  345 

such  as  is  furnished  by  Colorado  or  New  Mexico.  A  visit  of  a  few 
months  or  a  year  is  of  but  little  service.  I  have  used  the  iodids  and  the 
bichlorid  of  mercury  for  months  without  any  appreciable  improvement 
in  two  of  these  patients  who  could  not  be  removed  from  town.  The 
citrate  of  iron  and  quinin,  one  grain  in  a  dram  of  sherry  wine,  makes  a 
good  appetizer,  and  may  be  given  in  one-fourth  glass  of  water  after 
meals.  Its  use  can  with  advantage  be  alternated  with  that  of  the 
syrup  of  the  hypophosphites  (Gardner),  one  to  three  drams  being  given 
daily  in  one-half  glass  of  water  after  meals.  Cod-liver  oil  may  be  used 
with  advantage  for  ten  days  out  of  the  month,  but  its  continued  use  is 
contraindicated,  as  it  is  apt  to  interfere  with  digestion. 

In  one  of  the  cases  above  referred  to  the  iron  was  given  for  ten  days 
and  the  oil  for  ten  days,  after  which  the  procedure  was  steadily  repeated. 
The  patient  continued  to  look  well,  gained  in  weight,  and  remained 
under  treatment  until  he  took  up  an  occupation  and  passed  from  ob- 
servation. The  condition  of  the  lung  had  remained  unchanged,  the 
only  active  manifestation  of  the  disease  being  the  expectoration  of  a 
considerable  amount  of  non-tuberculous  pus  every  morning  on  rising. 

Infants  and  children  with  bronchiectasis  who  cannot  be  removed 
to  a  favorable  climate  should  have  the  advantages  of  outdoor  life,  and 
older  children  should  have  as  much  active  exercise  as  is  possible  with- 
out fatigue.  The  diet  and  general  management  are  the  same  as  for 
pulmonary  tuberculosis  (p.  361). 

Gymnastic  Therapeutics. — For  the  purpose  of  expansion  of  the  lung 
with  the  hope  of  curing  the  chest  deformity  gymnastic  exercises  are  of 
the  greatest  value.     (See  p.  803.) 

HYPOSTATIC  PNEUMONIA 

Hypostatic  pneumonia  is  a  form  of  lobular  pneumonia  which  de- 
velops in  fatal  cases  in  the  most  dependent  portions  of  the  lungs,  these 
portions  having  become  very  hyperemic  as  the  result  of  weakness  of  the 
heart  and  respiration  in  patients  who  are  severely  ill. 

The  affected  pulmonary  tissue  is  dark  red  in  color,  very  firm,  and 
airless.  On  section,  the  cut  surface  is  red  and  very  moist,  exuding 
blood  freely.  Microscopically,  the  capillaries  and  veins  are  distended 
with  blood,  and  the  alveoli  are  filled  with  red  blood-cells,  leukocytes, 
and  desquamated  epithelium.  The  bronchi  are  usually  in  good  condi- 
tion. The  extent  of  the  consolidation  varies.  While  it  usually  occu- 
pies only  a  superficial  strip  along  the  posterior  border  and  base  of  the 
lungs,  fully  half  of  the  lower  lobes  may  be  involved. 

PNEUMOTHORAX 

Air  in  the  pleural  cavity  may  be  due  to  tuberculosis,  or  to  trauma 
(usually  through  exploratory  puncture),  causing  perforation  of  the 
lung.  I  have  seen  one  case  of  this  nature.  Pneumothorax  also  maj^ 
occur  in  empyema.     By  far  the  most  frequent  cause  in  children  is  the 


346  THE    PRACTICE    OF    PEDIATRICS 

formation  of  a  cavity  in  the  course  of  tuberculosis,  supplying  a  commu- 
nication between  the  bronchi  and  the  pleural  cavity.  Artificial 
pneumothorax  has  been  advocated  as  a  means  of  treatment  for 
tuberculosis. 

Symptoms. — In  the  tuberculous  cases  the  symptoms  comprise  very 
sudden  onset  of  urgent  collapse,  urgent  dyspnea,  cyanosis,  and  rapid, 
feeble  pulse.  In  cases  due  to  trauma  the  symptoms  may  be  urgent  or 
scarcely  noticeable,  depending  upon  the  extent  of  the  lesion.  In  the 
case  referred  to,  which  developed  after  exploratory  puncture,  only  a 
moderate  amount  of  air  entered  the  pleural  cavity  and  no  inconven- 
ience was  occasioned. 

Physical  Signs. — The  physical  signs  are  determined  largely  by  the 
amount  of  air  entering  the  pleural  cavity.  They  may  include  simply 
hyperresonance  and  absence  of  respiratory  sounds.  In  cases  of  tuber- 
culous origin  there  is  usually  a  sudden  inrush  of  air,  with  resulting 
immobility  of  the  affected  side  and  enlargement  of  that  side  of  the 
thorax.  There  is  marked  hyperresonance,  and  an  absence  of  fremitus. 
In  cases  in  which  the  amount  of  air  is  not  excessive  there  will  be  tym- 
panitic dulness. 

Auscultation  reveals  very  weak  breath-sounds  or  entire  absence  of 
the  same.  The  coin  test  is  very  diagnostic.  A  coin  is  placed  on  the 
chest,  either  anteriorly  or  posteriorly,  and  tapped  with  another  coin 
by  an  assistant,  while  the  ear  of  the  examiner  is  placed  on  the  opposite 
aspect  of  the  same  half  of  the  chest.  The  sharp  metallic  sound  con- 
veyed, in  comparison  with  the  absence  of  sound  over  the  opposite  lung, 
furnishes  a  demonstration  to  students  that  will  never  be  forgotten.  If 
there  is  fluid  in  the  pleural  cavity,  splashing,  metallic,  tinkling  sounds 
may  be  heard. 

Prognosis. — The  prognosis  depends  upon  the  cause  of  the  air  in 
the  pleural  cavity.  The  tuberculous  cases  are  rapidly  fatal.  After 
trauma  the  recovery  depends  upon  the  nature  of  the  injury.  In  the 
case  referred  to  as  following  exploratory  puncture,  the  patient  re- 
covered without  treatment. 

Treatment. — In  empyema  the  fluid  should  be  removed  by  surgical 
procedures.  In  instances  in  which  there  is  marked  displacement  of 
the  heart  and  considerable  intrathoracic  pressure,  tapping  the  chest 
with  a  needle,  and  allowing  an  escape  of  the  air,  may  be  of  value. 

EMPHYSEMA 

Emphysema  is  a  secondary  disease.  There  are  few  autopsies  on 
children  dying  from  pulmonary  disorders  in  which  it  is  not  found  pres- 
ent in  greater  or  less  degree,  it  is  always  present  in  considerable 
degree  in  cases  of  interstitial  pneumonia,  and  in  this  association  the 
emphysema  is  compensatory  in  character.  It  is  found  with  whooping- 
cough,  bronchopneumonia,  habitual  spasmodic  bronchitis,  and  true 
asthma. 

Pathology. — Emphysema  is  most  frequently  found  in  a  pronounced 
degree  in  the  upper  lobes,  especially  at  the  anterior  borders  and  the 


SUBCUTANEOUS    EMPHYSEMA  347 

apices.  The  air-vesicles  are  persistently  dilated,  and  on  inspection,  to 
the  unaided  eye,  present  a  picture  of  innumerable  pin-point  air-bubbles. 
When  the  septa  give  way,  the  vesicles  enlarge  so  that  blebs  of  various 
size  occur.     The  condition  rarely  becomes  interlobular. 

Symptoms. — In  many  cases  there  is  no  special  manifestation,  and 
the  fact  that  emphysema  exists  is  discovered  only  at  the  autopsy. 
This  is  particularly  apt  to  occur  in  compensating  cases  in  which  there 
is  a  good  deal  of  lung  involvement,  as  in  interstitial  pneumonia  or  in 
prolonged  bronchopneumonia. 

When  there  has  been  repeated  spasmodic  bronchitis  or  true  asthma, 
there  is  shortness  of  the  breath,  with  rapid  breathing,  and  the  thoracic 
wall  presents  a  fixed  appearance,  owing  to  the  diminished  or  impercep- 
tible respiratory  excursion. 

The  so-called  barrel-shaped  chest  is  seen  in  children,  but  it  is  of  com- 
paratively infrequent  occurrence.  The  child  usually  has  a  dry  cough, 
is  incapable  of  the  usual  exertions  of  early  life,  and  readily  becomes 
cyanosed  through  air-hunger. 

Percussion. — There  is  increased  resonance  on  percussion,  general 
in  distribution,  but  most  marked  over  the  upper  lobes  in  front.  When 
the  emphysema  is  not  excessive,  tympanitic  dulness  may  be  elicited. 
The  area  of  cardiac  dulness  may  be  much  smaller  than  normal  or  en- 
tirely obliterated. 

Auscultation. — Upon  auscultation  the  respiratory  murmur  is  found 
to  be  feeble,  and  expiration  is  noticeably  prolonged  and  longer  than 
inspiration.  Squeaking,  small,  dry  rales  are  usually  heard  in  children 
because  of  the  almost  invariable  association  of  bronchitis.  The  rales 
are  heard  both  on  inspiration  and  on  expiration.  The  respiratory 
sounds  have  been  aptly  described  as  wheezing  in  character. 

Prognosis. — The  prognosis  in  general  emphysema  is  unfavorable. 
The  attacks  of  recurrent  asthma  or  recurrent  spasmodic  bronchitis, 
which  occasion  the  process,  continue,  and  the  condition  becomes  most 
pitiable.  Dilatation  of  the  right  .heart  ultimately  occurs.  Cardiac 
failure  and  acute  pulmonary  processes  are  the  usual  terminal  affections. 

Treatment. — The  management  is  that  of  the  associated  disease. 

SUBCUTANEOUS  EMPHYSEMA  (EMPHYSEMA  OF  THE  MEDIASTINUM) 

This  is  a  rare  condition  in  children.  I  have  seen  but  a  few  cases. 
Before  the  use  of  intubation,  when  tracheotomy  was  in  vogue,  many 
more  cases  were  seen  than  now.  Other  causes  may  be  pertussis,  tuber- 
culosis, or  trauma  to  the  lung.  The  first  occurrence  is  in  the  mediasti- 
num, whence  the  emphysema  extends  to  the  subcutaneous  tissues  and 
is  particularly  apt  to  appear  above  the  clavicles,  where  it  produces  a 
cushion-like  effect.  In  one  of  my  cases  the  emphysema  extended  from 
this  point  downward  over  the  thorax,  and  upward,  involving  the  entire 
neck. 

Prognosis. — Cases  following  operative  procedures  and  trauma  may 
recover.  When  the  condition  is  a  complication  of  pulmonary  disease, 
the  outlook  is  very  unfavorable. 


348  THE    PRACTICE    OF    PEDIATRICS 


PRIMARY  PLEURISY 


Acute,  primary  pleurisy  is  a  very  rare  condition  in  children.  I  have 
seen  but  five  cases  under  nine  years  of  age — one  patient  was  eight;  one, 
seven;  one,  four  years  of  age;  one,  two  and  a  half  years;  and  one,  only 
fifteen  months  old. 

Pathology. — In  these  cases  there  is  inflammation  of  the  pleura  with 
exudate,  but  usually  not  sufficient  inflammation  to  produce  an  appre- 
ciable exudate  in  the  pleural  cavity. 

Symptoms.^ — ^The  onset  of  the  disease  is  practically  the  same  as  in 
adults.  There  is  localized  pain — the  so-called  "stitch  in  the  side; "  the 
respiration  is  rapid — 40  to  60  to  the  minute — and  shallow;  the  skin  is 
dry  and  hot;  the  cough  is  teasing,  and,  on  account  of  the  pain  which  it 
causes,  is  partially  suppressed  by  the  patient.  Fever  is  present,  usu- 
ally ranging  from  102°  to  105°F.  The  pulse  is  rapid— 120  to  150  to  the 
minute.  In  two  of  my  cases  the  pleuritic  inflammation  was  followed 
by  effusion.  The  fluid  in  both  cases  was  sterile.  So  far  as  we  could 
learn,  there  was  no  associated  rheumatism  in  any  of  the  cases. 

Treatment. — The  treatment  which  proved  successful  in  the  five 
cases  was  rest  in  bed.  The  patients  were  given  a  reduced  diet  of  milk, 
broths,  and  gruel.  The  fever  was  not  of  a  very  persistent  character  and 
was  readily  controlled  by  sponge-baths  (p.  780).  A  flaxseed  and  mus- 
tard poultice, — one  part  of  mustard  to  nine  parts  of  flaxseed, — appHed 
as  hot  as  could  be  borne  by  the  back  of  the  nurse's  hand,  and  changed 
every  half-hour,  gave  much  relief  from  the  pain  during  the  acute  stage. 
After  the  first  twenty-four  hours,  however,  poultices  are  of  little  value. 
Strapping  the  affected  side  with  strips  of  Z.  O.  plaster  will  give  much 
comfort  when  the  pain  continues  after  the  second  day.  Tincture  of 
aconite  in  doses  of  one  drop  every  hour  was  given  to  the  older  children 
until  ten  drops  had  been  given.  It  produced  a  fairly  free  diaphoresis 
and  made  the  patients  more  comfortable.  A  grain  of  calomel  is 
divided  doses  was  given  early  in  the  attack,  }y{o  grain  being  given  every 
hour.  The  duration  of  the  acute  symptoms  was  ordinarily  from  twelve 
to  twenty-four  hours,  the  entire  duration  of  the  illness  ranging  from  five 
days  to  one  week.  In  the  case  of  effusion  in  the  youngest  child,  absorp- 
tion appeared  to  be  stimulated  by  the  introduction  of  the  needle  and  the 
withdrawal  of  a  small  amount  of  fluid,  the  remainder  quickly  disappear- 
ing afterward.  To  relieve  the  cough,  small  doses  of  codein,  }{o  grain 
every  two  hours,  were  given  the  older  children. 

Ultimate  Results. — That  these  cases  were  not  of  tuberculous  origin 
was  proved,  not  only  by  the  absence  of  the  tubercle  bacilli,  but  by  the 
complete  recovery  and  continued  good  health  of  each  patient  during 
the  next  few  years.  These  cases  antedated  the  von  Pirquet  test  for 
tuberculosis. 

SECONDARY  PLEURISY 

This  form  of  pleurisy  is  of  very  frequent  occurrence  in  the  young. 
Etiology. — In  by  far  the  larger  number  of  cases,  pleurisy  occurs  as 
a  complication  of  pneumonia. 


SECONDARY    PLEURISY  349 

Tuberculosis  is  probably  the  next  most  frequent  cause. 

Secondary  pleurisy  may  occur  with  pericarditis;  such  an  association 
however,  is  rare. 

Bacteriology. — Acute  fibrinous  (dry)  pleurisy  accompanying  pneu- 
monia in  children  is  caused  by  the  identical  bacterium  found  in  the 
consolidated  areas  of  lung  tissue.  This  type  of  pleurisy  is  more  com- 
mon with  lobar  pneumonia  than  with  bronchopneumonia. 

In  acute  serous  pleurisy  accompanying  pneumonia  small  numbers 
of  pneumococci  may  be  found  in  the  fluid.  Clear,  serous,  pleural 
fluid  containing  streptococci  has  been  described. 

In  the  tuberculous  cases  the  fluid  contains  the  tubercle  bacillus, 
demonstrable  by  staining  methods  or  by  intraperitoneal  injection  into 
guinea-pigs.  On  ordinary  culture-media  tuberculous  serous  fluids 
give  no  growth.  Pleurisy  with  serous  effusion  may  occur  with  acute 
rheumatism.  The  Poynton-Payne  diplococcus  of  rheumatism  has 
been  found  in  the  fluid  of  such  cases. 

Pathology. — Following  or  coincident  with  pneumonia  there  may 
occur  what  is  known  as  a  dry  pleurisy,  or  pleurisy  with  effusion.  When 
dry  pleurisy  exists,  the  pleura  loses  its  usual  luster,  and,  early  in  the 
attack,  is  covered  with  a  slight  fibrinous  exudate.  Exudation  may  go 
no  further  than  this,  or  it  may  become  most  extensive,  resulting  in  a 
network  of  thick,  fibrinous  bands,  in  the  meshes  of  which  there  is  a 
thick,  gelatinous  mass  composed  largely  of  fibrin  and  pus-cells. 

Repeatedly  at  autopsy  I  have  found  the  lung  so  thoroughly 
bound  to  the  chest-wall  that  its  removal  without  the  aid  of  force  was 
impossible. 

In  pleurisy  with  effusion  a  fluid  composed  either  of  pus  or  of  serum 
will  be  found  in  the  pleural  cavity.  I  have  never  seen  such  a  case  of 
pleurisy  secondary  to  pneumonia  in  which  the  effusion  did  not  contain 
bacteria.  The  fluid  upon  withdrawal  may  appear  clear,  yet  bacterio- 
logic  examination  will  show  that  it  is  not  sterile.  The  evidence  of 
bacteria  in  the  fluid  may  be,  and  often  is,  the  first  manifestation  of  a 
purulent  pleurisy  or  empyema. 

Pleurisy  of  tuberculous  origin  is  usually  of  the  dry  type.  Tubercles 
will  be  found  on  the  pleura,  and  there  is  more  or  less  exudation  of 
fibrin.  If  the  process  is  an  old  one,  there  is  considerable  thickening  of 
the  pleura,  with  very  firm  adhesions.  If  there  is  a  fluid,  it  usually 
exists  in  small  amount, — 1  to  4  ounces, — sacculated,  and  may  be 
serous  or  purulent. 

Symptoms. — Secondary  pleurisy  rarely  exhibits  distinct  symptoms 
of  its  own.  The  manifestations  are  a  part  of  the  disease  which  the 
pleurisy  complicates.  There  may  be  localized  pain,  but  this  is  rarely 
of  an  active  type.  A  sensation  of  tightness  or  constriction  is  more  com- 
mon. It  is  surprising  how  little  discomfort  is  present  in  a  vast  major- 
ity of  these  cases.  When  fluid  is  formed,  whether  serum  or  pus,  there 
are,  again,  no  active  symptoms  unless  the  fluid  is  excessive,  in  which 
event  there  will  be  interference  with  respiration,  and,  if  the  process  is 


350  THE    PRACTICE    OF    PEDIATRICS 

on  the  left  side,  the  heart  will  show  the  effects  of  the  pressure  by  rapid- 
ity and  perhaps  irregularity. 

The  influence  that  the  pleurisy  exerts  upon  the  temperature  is 
difficult  to  determine,  as  the  process  is  secondary  to  diseases  in  which 
temperature  is  a  prominent  feature.  If  the  exudation  is  purulent,  the 
temperature  may  take  on  the  characteristic  morning  drop  and  evening 
rise.  This  will  be  very  apt  to  occur  in  case  of  purulent  exudation  fol- 
lowing pneumonia,  which  is  discussed  in  the  following  chapter  under 
Empyema. 

Diagnosis. — The  diagnosis  is  dependent  more  upon  the  physical 
signs  than  upon  the  symptoms. 

Auscultation. — In  the  cases  without  fluid  exudate  auscultation 
will  often  show  either  fine  friction  rales,  which  may  be  heard  only  at 
the  end  of  inspiration,  or  the  dry-rubbing  friction  crepitus  heard  with 
both  inspiration  and  expiration.  In  the  presence  of  fluid  there  wiU  be 
weakness  of,  or  absence  of,  respiratory  murmur  over  the  area  covered 
by  the  exuded  fluid.  Rales  also  will  be  absent.  Over  the  uninvolved 
lung  area  there  will  be  an  exaggeration  of  the  normal  respiratory 
sounds. 

Percussion. — In  dry  pleurisy  there  is  no  perceptible  dulness;  the 
child  may  complain  that  the  percussion  is  painful.  With  fluid  there 
will  be  dulness  or  flatness,  depending  upon  the  amount  of  fluid  present. 
A  small  amount  usually  gives  circumscribed  dulness;  a  large  amount, 
extreme  dulness  or  flatness.  Over  the  uninvolved  portion  of  the  lung 
there  will  be  hyperresonance. 

Exploratory  Puncture. — Exploratory  puncture  not  only  definitely 
determines  the  presence  of  fluid,  but  also  its  nature. 

Treatment. — The  treatment  of  dry  secondary  pleurisy  is  usually 
that  of  the  disease  which  the  pleurisy  complicates.  I  have  never 
known  special  medication  to  be  of  any  practical  value.  Tonics  and 
supportive  measures  generally  are  of  service.  Anything  that  will 
improve  the  condition  of  the  patient  should  be  brought  into  use.  A 
change  of  residence  from  the  city  to  the  country  for  those  who  can 
afford  it,  or  an  outdoor  life  in  the  city  for  those  who  cannot  avail  them- 
selves of  such  a  change,  is  always  beneficial.  Counterirritation  to  the 
chest  with  mustard  or  iodin  will  often  give  relief  to  the  patient  if  there 
is  pain,  but  otherwise  this  measure  possesses  no  value.  When  there  is 
a  sense  of  ''tightness"  and  constriction  of  the  chest  which  amounts  to 
pain,  mustard  or  iodin  will  relieve  the  discomfort.  Painting  the 
affected  area  with  tincture  of  iodin  every  second  or  third  night  has,  in 
a  few  cases,  afforded  some  relief.  The  administration  of  iodids  as 
an  aid  to  absorption  is  of  questionable  value,  and  is  very  apt  to 
disturb  the  digestion.  The  application  of  a  mustard  plaster  (p. 
328) — one-third  mustard  and  two-thirds  flour — to  the  bare  skin  over 
the  diseased  area  for  ten  or  fifteen  minutes,  at  intervals  of  six  or  eight 
hours,  will  add  to  the  comfort  of  the  patient.  When,  after  recovery 
from  the  pneumonia  or  the  empyema,  adhesions  persist,  compelling 
restricted  lung  action,  active  exercise  in  the  open  air  is  to  be  en- 


EMPYEMA    (pleurisy   WITH   PURULENT   EFFUSION)  351 

couraged.  For  younger  patients  horseback-riding,  the  bicycle,  and 
breathing  exercises,  with  physical  games  which  call  for  active  interest 
and  require  deep  breathing,  do  better  than  anything  else  (p.  803). 

Presence  of  Fluid. — If  the  exploratory  puncture  shows  the  presence 
of  serum,  the  fluid  is  best  left,  with  the  hope  that  it  will  be  absorbed, 
unless  it  is  in  sufficient  amount  to  compromise  the  respiratory  function 
and  the  action  of  the  heart.  In  such  an  event,  several  ounces  should  be 
removed  by  aspiration.  In  many  cases  the  fluid  has  rapidly  disap- 
peared after  one  aspiration.  The  aspiration  may  be  repeated  if  nec- 
essary. During  this  operation  care  should  be  exercised  to  observe 
absolute  asepsis.  I  have  known  cases  to  become  rapidly  purulent 
after  the  insertion  of  a  needle.  There  is  always  a  question  in  such 
instances,  how  much  infection  has  been  carried  in  on  the  needle. 

Preparation  of  the  Skin  for  an  Aspiration. — The  skin  should  be 
thoroughly  scrubbed  with  green  soap.  This  is  to  be  followed  by  wash- 
ing with  alcohol,  and  then  with  equal  parts  of  alcohol  and  tincture  of 
iodin.,  The  hands  should  be  cleaned,  and  the  instrument  used  should 
be  sterilized,  as  for  a  surgical  operation. 

If  the  pleurisy  is  of  tuberculous  origin,  no  particular  management 
is  carried  out  other  than  that  of  the  primary  disease,  except  in  the 
event  of  symptoms  of  pain.  This  is  to  be  relieved,  as  already  de- 
scribed, by  the  use  of  local  applications  of  mustard  and  iodin,  with  per- 
haps the  administration  of  a  sedative,  such  as  small  doses  of  codein. 

Dry  pleurisy  associated  with  pericarditis  does  not  call  for  treat- 
ment other  than  that  of  the  pericarditis,  excepting  in  instances  which 
call  for  the  relief  of  pain. 

EMPYEMA  (PLEURISY  WITH  PURULENT  EFFUSION) 

In  empyema  there  is  a  collection  of  pus  in  the  pleural  cavity,  re- 
sulting from  inflammation  of  the  pleura  which  has  become  infected 
with  pathogenic  organisms. 

Age. — A  vast  majority  of  the  cases  occur  in  infants  and  children 
under  four  years  of  age.  My  youngest  patient  was  three  weeks  old, 
and  this  child  recovered.  Comparatively  few  cases  develop  after 
the  tenth  year. 

Etiology. — In  95  per  cent,  of  my  cases  the  disease  has  occurred  with 
evident  pneumonia.  Empyema  may  follow  suppurative  processes 
in  any  part  of  the  body,  but  such  cases  are  extremely  rare. 

Bacteriology. — The  pneumococcus  is  found  in  pure  culture  in  the 
pus  in  about  75  per  cent,  of  all  cases  in  children.  The  streptococcus 
is  less  commonly  present,  and  the  Staphylococcus  aureus  is  very  rarely 
found.  B.  influenzae  has  been  found  in  pure  culture  in  purulent 
pleural  fluid  after  influenzal  pneumonia,  and  B.  typhosus  may  cause 
empyema  during  an  attack  of  typhoid  fever.  In  cases  of  empyema 
following  inflammatory  conditions  in  the  abdomen  (appendicitis  or 
peritonitis)  B.  coli  communis  has  been  isolated. 

Purulent  effusion  accompanying  pulmonary  tuberculosis  may  con- 


352  THE    PRACTICE    OF    PEDIATRICS 

tain  the  tubercle  bacillus,  but  pyogenic  cocci  also  are  almost  always 
present. 

Pathology. — A  purulent  pleural  exudation  may  follow  serous  in- 
flammation of  the  pleura,  or  the  process  may  be  a  purulent  one  from 
the  outset.  The  pus  may  be  thin  or  thick,  yellowish  or  greenish  in 
color,  and  it  may  contain  large  masses  of  fibrin.  The  quantity  of  puru- 
lent fluid  may  vary  from  a  few  ounces  to  30  to  40  ounces  or  more  in 
neglected  cases.  "  While  the  inflammation  may  involve  the  entire 
pleural  surface  of  one  lung,  it  is  more  often  limited  to  the  lower  lobe 
and  to  the  posterior  portion.  Both  pleural  cavities  may  be  involved. 
The  pulmonary  and  costal  surfaces  of  the  pleura  are  usually  covered 
with  a  fibrinopurulent  exudate,  and  adhesions  between  the  pleural 
surfaces  and  between  the  pleura  and  pericardium  are  readily  separated 
at  this  stage.  The  lung  substance  beneath  the  exudate  is  more  or  less 
compressed,  according  to  the  amount  of  pus  present.  In  extreme 
cases  the  affected  lung  portion  may  be  completely  airless,  bloodless, 
gray  in  color,  smaller  than  normal,  and  flattened  against  the  vertebral 
column.  The  heart  may  be  pressed  toward  the  healthy  side.  In  less 
severe  cases  the  lung  may  be  congested,  and  still  contain  some  air. 

Empyema  may  heal  completely  in  the  early  stage.  Very  often, 
however,  it  tends  toward  a  chronic  course.  The  pus  frequently  be- 
comes very  thick,  the  formation  of  granulation  tissue,  and  later  of 
fibrous  connective  tissue,  causes  irregular  thickening  of  the  pleura. 
Adhesions  between  the  pleural  surfaces  may  thus  be  so  dense  as  to  make 
separation  impossible,  and  an  encapsulated  empyema  may  be  formed 
by  the  shutting  off  of  a  smaller  or  larger  amount  of  pus  by  adhesions. 
The  connective-tissue  formation  may  even  extend  into  the  lung  sub- 
stance, resulting  in  interstitial  pneumonia. 

In  cases  of  empyema  which  come  to  autopsy  early  in  the  disease  the 
pneumonia  preceding  the  empyema  may  still  be  present.  In  later 
stages,  however,  only  a  complicating  bronchopneumonia,  acute  or 
chronic,  may  be  found  in  one  or  more  of  the  lobes  not  involved  by  the 
empyema,  or  an  interstitial  pneumonia  in  that  portion  of  the  lung  sub- 
stance beneath  the  thickened  pleura. 

In  untreated  cases  the  pus  may  be  evacuated  through  a  bronchus, 
externally  through  the  chest-wall,  or  into  the  peritoneal  cavity. 

Symptoms. — The  child  has  a  catarrhal  pneumonia  or  a  broncho- 
pneumonia, running  the  usual  course  as  to  fever,  respiration,  pulse,  and 
prostration.  After  a  time  varying  from  six  to  twelve  days  an  improve- 
ment in  the  symptoms  is  noticed,  the  pulse  and  respiration  become 
slower,  and  the  child  appears  brighter.  For  twenty-four  to  forty- 
eight  hours  the  temperature  range  is  quite  low.  During  the  height  of 
the  pneumonia  it  has  been  perhaps  104°F.  to  105°F.  Now  the  tem- 
perature ranges  from  100°F.  to  102°F.,  at  times  dropping  to  99°F. 
Soon  it  becomes  noticeable  that  the  temperature  is  higher  in  the  even- 
ing than  in  the  morning,  although  the  evening  temperature  may  not  be 
above  102°F.,  or  at  most  103°F.  The  child  coughs,  the  pulse  is  rapid, 
— 120  to  140, — and  the  respiration  is  accelerated  to  40  or  more.     The 


EMPYEMA    (pleurisy   WITH    PURULENT   EFFUSION)  353 

appetite  is  poor.     These  or  similar  symptoms  may  continue  for  weeks 
if  the  condition  is  not  recognized. 

Empyema  After  Lobar  Pneumonia. — -More  cases  of  empyema  follow 
lobar  pneumonia  than  the  catarrhal  type.  The  following  sympto- 
matology covers  a  majority  of  the  cases:  The  crisis  occurs,  and  the 
temperature  falls  to  normal  (see  Fig.  43)  and  remains  normal  for 
a  few  days ;  or  perhaps  there  is  the  temporary  postcritical  rise  the  day 
following  the  crisis.  In  other  respects  conditions  continue  favorable 
for  perhaps  two,  three,  or  rarely  five  days,  when  a  slight  evening  rise 


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in  temperature  occurs.  The  temperature  is  lower  the  next  morn- 
ing, but  perhaps  not  quite  normal;  the  following  evening  it  is  higher 
than  the  preceding,  and  the  next  evening  it  is  still  higher.  Such  a 
temperature  range  following  pneumonia  is  almost  pathognomonic 
of  empyema  (Fig.  44). 

In  some  few  cases  the  exudation  of  pus  into  the  pleural  cavity  is  not 
delayed  until  the  temperature  falls,  but  develops  during  the  first  few 
days  of  the  pneumonia.  With  the  formation  of  pus  the  respiration  and 
pulse  increase  in  frequency,  the  respiration  ranging  above  40,  and  the 
pulse  from  140  to  180.  It  is  a  mistake,  however,  invariably  to  expect 
characteristic  signs.  The  lungs  and  heart  soon  accommodate  them- 
selves to  the  changed  conditions.  Repeatedly  I  have  seen  cases  in 
which  there  was  but  slight  acceleration  of  the  pulse  and  respiration. 
The  evening  temperature,  however,  is  rarely  less  than  102°F.  In  addi- 
tion to  the  symptoms  enumerated,  these  cases  (particularly  those  that 
have  continued  for  tv/o  weeks  or  longer)  show  a  symptom-complex  that 
may  almost  be  said  to  be  characteristic.  The  child  is  emaciated  and 
23 


354 


THE    PRACTICE    OF   PEDIATRICS 


the  face  wears  an  anxious  expression.  The  skin  is  pale,  of  a  yellowish 
tinge,  and  perspires  readily.  The  mucous  membrane  and  conjunctivse 
are  pale.  Slight  exertion  causes  embarrassment  of  the  respiration. 
The  nostrils  are  distended;  the  respiration  during  rest  is  short,  and  in- 
creased from  10  to  20  per  minute  above  the  normal.  The  fingers  may 
show  signs  of  clubbing. 

Diagnosis. — Diagnosis  is  based  upon  physical  examination  of  the 
chest  and  exploratory  puncture.  Weakness  or  absence  of  respiratory 
murmur  and  absence  of  rales,  combined  with  the  presence  of  dulness  or 
flatness,  are  indications  justifying  an  exploratory  puncture. 


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Fig.  44. — Empyema  following  lobar  pneumonia.     Operation.     Recovery  case. 


When  the  disease  is  located  on  the  left  side,  the  displacement  of  the 
heart  to  the  right,  as  indicated  by  the  changed  position  of  the  apex-beat, 
is  a  very  suggestive  sign.  Over  the  uninvolved  portion  of  the  chest, 
auscultation  will  show  exaggerated  respiratory  murmur;  and  percus- 
sion, hyperresonance. 

Differential  Diagnosis. — (Blood  examination,  p.  397).  Empyema 
is  to  be  differentiated  from  serous  pleurisy,  pleurisy  with  massive 
exudation  of  fibrin,  unresolved  pneumonia,  pulmonary  tuberculosis, 
malaria,  and  typhoid  fever. 

Serous  pleurisy  and  pleurisy  with  a  thick,  fibrinous  exudate  give 
signs  identical  with  those  of  empyema.  In  many  cases  of  fibrinous 
pleurisy  with  a  considerable  exudate,  not  a  rale  or  friction-sound  will  be 
heard.  Our  only  means  of  differentiating  empyema  from  these  proc- 
esses is  in  an  exploratory  puncture  with  a  large  needle. 

In  unresolved  pneumonia  the  respiratory  sounds  are  heard  with 
greater   distinction.     Riles,    and  often  friction-sounds,    are  present. 


EMPYEMA    (pleurisy    WITH    PURULENT    EFFUSION)  355 

The  dulness  is  distinctly  localized,  and  there  is  rarely  flatness  unless 
there  is  associated  with  the  pneumonia  a  thick  pleuritic  exudate. 

In  tuberculosis  of  the  lung  of  sufficient  gravity  to  allow  of  confusion 
the  presence  of  tubercle  bacilli  in  smears  from  the  expectoration  or 
tracheal  secretion  (see  p.  362)  may  determine  the  diagnosis.  The  von 
Pirquet  test  (p.  702)  may  be  brought  into  use.  Here  also,  however, 
the  exploratory  puncture  is  the  best  means  of  establishing  the  diagnosis. 

The  difficulties  in  differentiating  typhoid  fever  and  malaria  from 
empyema  should  be  slight,  in  view  of  the  marked  dissimilarity  in  the 
disease  conditions.  Nevertheless,  cases  of  empyema  are  not  infre- 
quently treated  for  typhoid  and  malaria  when  pus  is  apparent  in  the 
pleural  cavity.  When  the  lungs  are  proved  normal  by  competent 
physical  examination,  then  the  tests  for  malaria  and  typhoid  in  daily 
use  may  be  instituted. 

Treatment. — When  pus  is  located,  operation  and  drainage  are  the 
only  methods  of  treatment.  Aspiration  is  never  to  be  looked  upon  as 
a  substitute  for  incision. 

In  a  recent  case  in  a  young  child  under  two  years  of  age  an  incision 
with  local  anesthesia — ethyl  chlorid  answers  the  purpose — is  all  that 
will  be  required.  In  the  case  of  an  older  child,  or  in  a  prolonged  case 
in  a  young  child,  a  resection  of  the  rib  is  to  be  advised  as  furnishing 
much  freer  drainage.  Occasionally  cases  are  seen  among  older  chil- 
dren in  which,  on  account  of  a  very  severe,  persisting  pneumonia,  it  will 
not  be  safe  to  use  a  general  anesthetic.  In  such  cases  an  incision  may 
be  made  under  cocain — a  4  per  cent,  solution  being  injected  into  the 
skin  at  the  site  of  the  proposed  incision.  Such  an  operation  will  relieve 
the  immediate  symptoms — the  displacement  of  the  heart  and  the 
difficult  breathing.  The  resection  of  a  rib  may  safely  be  undertaken 
after  a  week  or  two,  when  considerable  improvement  will  have  taken 
place  in  the  general  condition.  As  soon  as  the  cavity  is  opened, 
two  half-inch  drainage-tubes,  from  two  to  four  inches  in  length, 
joined  with  a  large  safety-pin,  are  inserted.  Gauze  is  packed  around 
the  tubes  and  against  the  skin,  and  upon  this  the  pin  rests.  Sterile 
gauze  is  placed  over  the  end  of  the  tubes  as  soon  as  possible  after 
their  introduction,  in  order  to  prevent  too  free  escape  of  pus.  When 
the  pus  is  allowed  gradually  to  escape,  much  less  shock  will  be  experi- 
enced. Over  the  gauze,  two  or  three  layers  of  absorbent  cotton  are 
placed,  and  over  this  the  bandage.  The  dressing  should  be  changed 
every  day  and  the  tubes  shortened  as  the  lung  expands.  This  ex- 
pansion will  be  indicated  by  the  resulting  outward  displacement  of 
the  tubes.  After  the  evacuation  of  the  pus  the  pulse  usually  falls  to 
normal  or  nearly  normal,  where  it  remains.  Occasionally,  however, 
cases  are  seen  in  which  this  expected  result  does  not  follow  the 
operation. 

Illustrative  Case. — In  one  of  my  cases  the  operation  was  followed  by  a  free  dis- 
charge of  pus,  but  with  no  relief  whatever  to  the  symptoms.  An  examination  of 
the  chest  revealed  at  the  apex  of  the  lung  a  pocket  of  pus  which  had  become  walled 
off  by  adhesions.  The  case  was  one  of  three  months'  duration  when  it  came  under 
my  care.     A  second  operation  removed  about  six  ounces  of  pus,  but  the  child  died 


356  THE    PRACTICE    OF    PEDIATRICS 

from  exhaustion  about  twenty-four  hours  afterward.     Autopsy  showed  that  the 
pleural  cavity  was  divided  into  two  distinct  pus-sacs  by  a  firm  band  of  adhesions. 

Failure  of  the  temperature  to  subside  in  my  cases  in  which  compUca- 
tions  could  be  excluded  has  been  due  to  defective  drainage.  The  tube 
may  be  too  small  or  plugged,  or  the  pus  may  become  sacculated.  Large 
fibrinous  masses  which  the  tube  will  not  admit  may  undergo  slow  de- 
generation and  absorption  and  continue  the  temperature. 

Illustralive  Case. — In  a  case  of  empyema  following  a  pneumonia  of  great  severity 
in  a  girl  of  five  years,  on  account  of  the  reduced  condition  of  the  child  an  incision 
was  made  instead  of  a  resection  of  the  rib.  The  temperature  fell  to  normal,  and 
all  the  symptoms  improved  for  a  few  days,  when  an  evening  rise  to  101°F.  and  over 
was  noted,  which  in  two  or  three  days  reached  103°F.  There  was  a  discharge 
which  saturated  the  dressings,  although  they  were  changed  every  three  or  four 
hours.  Our  inability  to  locate  an  independent  pus-pocket,  the  continued  fever, 
and  a  strong  odor  to  the  discharge  suggested  the  probability  of  insufficient  drainage. 
In  spite  of  the  fever,  the  child  having  gained  considerably  in  strength,  a  second 
operation  was  decided  upon  to  enlarge  the  wound.  She  was  anesthetized,  and 
two  inches  of  rib  were  removed,  whereupon  quantities  of  necrotic  fibrinous  material 
were  found  in  the  pleural  cavity.  These  were  removed  with  the  finger  and  dressing 
forceps;  the  temperature  immediately  fell  to  normal,  and  the  child  made  a  perfect 
recovery.     Irrigation  of  the  cavity  had  been  of  no  avail. 

Ordinarily  the  tubes  should  not  be  removed  until  from  four  to  six 
weeks  after  the  operation.  At  least  one  tube  should  be  kept  in  posi- 
tion until  a  free  respiratory  murmur  is  heard  all  over  the  affected  side, 
up  to  the  site  of  operation  in  the  chest-wall.  When  the  lung  is  fully 
expanded,  the  tubes  will  be  forced  out  and  found  in  the  dressings.  Irri- 
gation of  the  pleural  cavity  is  not  to  be  advised  as  a  routine  measure, 
and  with  sufficient  drainage  it  will  not  be  found  necessary.  The  cases 
which  require  irrigation  on  account  of  continued  fever  and  insuffi- 
cient discharge  require  a  resection  of  the  rib.  Should  a  second  opera- 
tion be  refused,  on  account  of  the  tender  age  or  the  general  weakness 
of  the  patient,  or  be  inadvisable  on  account  of  some  complication, 
such  as  a  pericarditis,  a  daily  irrigation  with  a  sterile  normal  salt 
solution  may  be  undertaken. 

Deformity  Following  Untreated  Cases. — In  hospital  and  out-patient 
work,  cases  neglected  for  weeks,  showing  marked  chest  deformity  and 
retraction,  usually  associated  with  spinal  curvature,  are  among  those 
treated.  The  pus  has  been  partially  absorbed  and  partially  organized, 
leaving  extensive  adhesions  which  have  bound  the  lung  tightly  to  the 
chest-wall,  preventing  expansion,  so  that  the  bony  wall  has  become  dis- 
placed inward  to  meet  the  lung.  For  these  unfortunate  children  surgi- 
cal measures  furnish  some  relief,  but  the  results  in  my  cases  have  not 
been  brillant. 

Treatment  by  Siphon  Drainage. — The  siphon  drainage,  often 
named  after  Bulan,  but  previously  used  by  Playfair,  has,  during  the 
past  five  years,  been  considerably  modified  and  made  more  efficient 
by  Kenyon,  of  New  York.  This  method  is  particularly  useful  in  treat- 
ing infants.  For  detailed  description  see  "Siphon  Treatment  of  Em- 
pyema in  Infants,"  by  Holt:  American  Medicine,  new  Series,  vol. 
viii,  No.  6,  pp.  381-389. 


EMPYEMA    (pleurisy    WITH    PURULENT    EFFUSION)  357 

Procedure. — An  ordinary  aspirating  needle  attached  to  a  short 
rubber  tube  (2  to  3  inches)  which  fits  closely  to  a  glass  Luer  syringe  is 
introduced  into  the  chest  in  the  seventh  or  eighth  space  in  the  scapular 
line,  and  the  presence  or  absence  of  pus  ascertained.  The  introduction 
of  the  needle  should  take  place  just  below  the  lower  border  of  the  rib, 


Fig,  45. — Tube  with  window,  cuff,  and  tape;  bottle  with  long  and  short  glass 
tubes,  half  filled  with  salt  solution;  the  long  tube  is  always  below  the  level  of  the 
fluid  (Kenyon). 


in  order  to  avoid  the  artery.  The  larger  portion  of  the  pus  should  be 
aspirated  with  the  syringe,  as  this  considerably  simplifies  the  procedure 
thereafter.  After  completion  of  this  step  the  rubber  tube  is  clamped 
and  the  syringe  removed. 

A  bistoury  is  inserted  into  the  pleural  cavity  along  the  needle ;  this 
puncture  wound  is  now  enlarged  between  the  needle  and  the  rib  below 


358 


THE    PRACTICE    OF    PEDIATRICS 


it.  The  incision  should  be  the  size  of  the  drainage-tube,  and  not  as 
large  as  the  cuff;  in  this  manner  the  drainage-tube  with  cuff  attachment 
will  be  found  to  fit  most  snugly. 

The  apparatus  consists  of  a  bottle,  and  rubber  drainage-tube,  the 
former  of  about  one  pint  capacity,  and  filled  three-quarters  full  of 
warm  saline.  The  vessel  is  equipped  with  a  perforated  rubber  cork 
into  which  fit  two  glass  tubes,  one  just  through  the  cork  and  the  other 
reaching  almost  to  the  bottom,  and  connecting  by  its  outer  end  with 

the  drainage-tube.  The 
tube  is  made  of  stiff  rub- 
ber, inside  diameter  being 
/■ie  to  yg  inch  and  the 
wall  of  about  }{q  inch 
thickness.  A  soft-rubber 
tube  collapses  too  readily 
and  will  not  do.  A  window 
is  cut  near  the  end  of  the 
tube,  and  a  narrow  piece 
of  tubing,  fully  3^:4  inch 
long  and  from  ^fg  to  ^{q 
inch  inside  diameter,  is 
stripped  over  the  drainage- 
tube,  leaving  about  1  to 
13-^  inches  protruding — 
just  sufficient  to  enter  the 
pleural  cavity  and  effect 
drainage.  Over  the  drain- 
age-tube is  threaded  a 
piece  of  tape  (button- 
holed) about  }'2  inch  wide 
and  5  to  6  inches  long. 
This  is  made  to  fit  snugly 
over  the  cuff,  and  in  this 
manner  helps  to  retain  the 
tube  within  the  pleural 
cavity. 
The  drainage-tube  is  inserted  into  the  chest  by  means  of  an  ordinary 
artery  clamp.  The  tape  is  drawn  tightly  over  the  chest  and  made  fast 
with  adhesive  strapping.  The  latter  may  be  built  "up"  around  the 
tube,  thus  adding  further  protection  against  leakage,  and,  in  addition, 
serving  to  anchor  the  tube  within  the  chest.  Some  split  gauze  around 
the  tube  fastened  with  adhesive  completes  the  dressing.  In  order  to 
promote  siphonage  the  bottle  is  raised  above  the  patient  and  some  of 
the  saline  is  permitted  to  run  into  the  chest,  in  this  manner  increasing 
the  fluidity  of  its  contents.  Usually  the  expansile  power  of  the  lung  is 
sufficient,  with  a  little  stripping  of  the  tube,  to  effect  immediate  drainage. 
Occasionally  it  will  be  observed  that  very  little  or  no  pus  drains  during 
the  first  twenty-four  hours  or  so,  and  that  a  great  deal  of  air  bubbles 


Fig.  46. — Dressing  complete  (Kenyon). 


EMPYEMA    (pleurisy    WITH    PURULENT    EFFUSION)  359 

into  the  bottle,  along  with  some  blood-stained  fluid.  In  these  cases 
it  may  safely  be  assumed  that  the  lung  itself  has  been  punctured  and 
the  tube,  in  these  instances,  should  be  shortened.  The  infant  may  be 
placed  in  bed,  propped  in  such  a  manner  as  to  effect  the  best  drainage. 

During  the  first  day  or  two  it  is  usually  necessary  to  empty  the 
bottle  two  or  three  times,  and  in  order  to  do  this  the  rubber  tube  is  dis- 
connected from  the  bottle  and  the  end  covered  with  gauze  and  clamped. 
If  the  discharge  is  very  thick,  the  chest  may  be  irrigated  in  the  manner 
described  above.  With  effectual  drainage  the  temperature  usually 
drops  within  twenty^four  hours  provided  an  extension  of  the  pneu- 
monic process  is  not  present.  A  sudden  rise  is  always  suggestive  of 
a  plugging  of  the  tube  with  fibrin  clots,  and  should  be  investigated  by 
removing  the  tube  and  inserting  a  fresh  one.  Sometimes  a  larger 
tube  is  necessary  in  order  to  effect  better  drainage. 

The  average  time  for  leaving  the  tube  in  the  chest  is  from  two  to 
three  weeks,  although  in  protracted  cases  drainage  is  sometimes  neces- 
sary for  two  months.  With  a  normal  temperature,  general  improve- 
ment in  the  child's  condition,  cessation  of  discharge,  and  absence  of 
leukocytosis  the  tube  may  usually  be  safely  removed.  Rarely  is  it 
necessary  to  reinsert  the  tube.  In  cases  coming  to  autopsy  either 
through  extension  of  the  pneumonic  process  or  from  general  sepsis,  the 
drainage  has,  without  exception,  been  complete. 

The  advantages  claimed  for  this  method  may  be  summarized  as 
follows : 

1.  Simplicity  and  facility  of  the  operation. 

2.  Freedom  from  shock. 

3.  Absence  of  pneumothorax. 

4.  Single  dressings  which  do  not  require  frequent  changings,  and 
thereby  lessen  the  danger  of  a  mixed  infection. 

5.  Shortened  convalescence. 

6.  Efficiency  of  the  drainage. 

Double  Empyema. — But  two  cases  coming  under  my  observation 
have  had  both  pleural  sacs  involved.  In  such  cases  both  sides  should 
not  be  opened  at  the  same  time,  on  account  of  the  danger  of  collapse  of 
the  lungs.  There  are. usually  adhesions  present  sufficiently  strong  to 
prevent  this,  but  we  have  no  means  of  knowing  this  beforehand.  In 
both  of  my  cases  the  left  pleural  cavity  was  opened  first,  in  order  to 
relieve  the  pressure  upon  the  heart  and  the  great  vessels. 

Illustrative  Cases. — In  one  case  a  considerable  quantity  of  pus  was  removed  from 
the  right  side  by  aspiration  at  the  time  of  the  operation  on  the  left  side.  The  right 
side  was  operated  upon  four  days  later,  by  which  time  sufficient  adhesions  had 
formed  to  prevent  collapse  of  the  lungs.  The  patient,  a  boy  of  two  years,  made 
an  excellent  recovery. 

The  second  patient  was  one  year  of  age.  Pus  had  been  present  in  both  sides  for 
a  considerable  time.  The  left  side  was  opened  first.  The  sac  on  the  right  side  was 
smaller  than  that  on  the  left,  and  was  operated  on  by  incision  three  days  later. 
The  child  was  very  much  reduced  by  the  protracted  illness.  In  spite  of  the  free 
daily  irrigation  of  both  cavities,  the  typical  temperature  persisted  until  death, 
probably  on  account  of  the  very  extensive  suppurating  surfaces.  The  child  died 
from  exhaustion  twelve  days  after  the  second  operation. 


360  THE    PRACTICE    OF    PEDIATRICS 

Empyema  Necessitatis. — Spontaneous  rupture  of  the  pleural  sac 
may  occur  in  cases  of  empyema  of  considerable  duration  which  are  not 
properly  diagnosed  or  not  operated  upon  if  diagnosed.  Cases  of  this 
nature  have  been  reported  in  which  the  pus  ruptured  into  the  esopha- 
gus, into  the  bronchi,  or  through  the  diaphragm  into  the  peritoneal 
cavity. 

Illustrative  Cases. — In  two  of  the  cases  seen  by  me  spontaneous  rupture  oc- 
curred. In  the  first,  pus  ruptured  into  the  bronchi.  The  patient  was  a  well- 
nourished  boy  three  j^ears  of  age.  The  pus  was  sacculated  over  the  anterior 
portion  of  the  left  lung.  The  parents,  not  particularly  intelligent  people,  objected 
to  the  operation,  and  while  it  was  under  consideration  by  them,  two  or  three  days 
after  the  diagnosis  was  made,  the  pus  ruptured  into  the  bronchi  and  was  discharged 
from  the  mouth  in  large  quantities  during  a  coughing  paroxysm.  The  child  made 
an  uninterrupted  recovery. 

The  other  patient,  a  boy  of  two  years,  came  under  observation  for  a  soft 
fluctuating  swelling,  the  size  of  a  small  orange,  on  the  right  side,  immediately  below 
the  nipple.  Exploration  with  a  hypodermic  needle  showed  pus.  An  incision 
was  made  and  about  three  ounces  of  pus  discharged.  When  the  sac  was  emptied, 
it  was  found  to  communicate  with  the  right  pleural  cavity  by  an  opening  between 
the  seventh  and  eighth  ribs.  The  wound  was  dressed  and  the  child  recovered 
without  further  complications. 

PULMONARY  GANGRENE 

Pulmonary  gangrene  is  a  very  rare  complication  of  pneumonia. 
I  have  seen  but  three  cases,  all  of  which  developed  during  the  course  of 
a  bronchopneumonia.  The  gangrene  is  supposed  to  be  due  to  an  em- 
bolism of  some  branch  of  the  pulmonary  artery,  or  to  a  septic  throm- 
bosis. The  odor  of  the  breath  is  most  characteristically  offensive, 
and  is  in  itself  diagnostic.  As  a  complication  of  pneumonia  pulmonary 
gangrene  is  invariably  fatal. 

Except  for  the  odor  of  the  breath,  there  are  no  significant  symptoms 
which  may  not  exist  with  the  usual  attack  of  bronchopneumonia. 

PULMONARY  ABSCESS 

Pulmonary  abscess  is  a  very  unusual  complication  of  pneumonia. 
At  any  rate,  comparatively  few  cases  are  diagnosed,  because  of  the 
occurrence  of  the  abscess  with  empyema  or  because  symptoms  re- 
sembling empyema  are  present.  The  abscess  is  usually  discovered 
during  exploration  for  pus  in  the  pleural  cavity. 

Illustrative  Case. — The  only  case  of  this  nature  that  has  occurred  under  my 
personal  observation  was  that  of  a  patient  two  years  of  age.  The  case  was  one  of 
the  first  in  my  private  practice.  The  child  had  a  pneumonia  of  the  right  upper 
lobe,  which  failed  to  resolve  after  abatement  of  the  urgent  symptoms.  The 
temperature  continued  at  101°  to  102°F.,  and  there  was  a  distressing  cough. 
The  family  were  becoming  restless,  and  my  patient  was  about  to  pass  into  other 
hands,  when,  at  the  family's  suggestion,  I  changed  the  medication  and  gave  a 
mixture  containing  full  doses  of  syrup  of  ipecac  and  ammonium  chlorid.  This  was 
given  repeatedly  without  dilution,  against  instructions,  and  produced  violent 
emesis.  During  a  vomiting  seizure  the  child  brought  up  a  considerable  amount  of 
pus,  after  which  the  recovery  was  prompt.  Evidently  the  straining  had  produced 
a  rupture  of  a  pulmonary  abscess  into  one  of  the  larger  bronchi. 


PULMONARY    TUBERCULOSIS  361 


PULMONARY  TUBERCULOSIS 


Infection  of  the  lungs  with  the  tubercle  bacillus  furnishes  the  chief 
manifestation  of  tuberculosis  in  the  human.  The  lungs  are  the  most 
active  seat  of  the  process  in  at  least  90  per  cent,  of  the  cases. 

Pathology. — In  the  most  acute  form  of  pulmonary  tuberculosis 
the  lungs  contain  gray,  translucent  tubercles  in  varying  numbers. 
These  may  be  only  few  in  number,  or  both  lungs  may  be  very  closely 
studded  with  them.  The  lesions  may  also  be  present  on  both  surfaces 
of  the  pleura.  Acute  bronchopneumonia,  with  or  without  fibrinous 
pleurisy,  may  exist.  In  a  late  stage  the  tubercles  undergo  cheesy 
degeneration  and  are  yellow  in  color.  The  coalescence  of  neighboring 
tubercles  may  give  rise  to  cheesy  masses,  which  eventually  undergo 
softening.  The  tubercles  are  more  often  peribronchial  than  perivas- 
cular in  distribution.  Owing  to  the  more  direct  course  of  the  right 
main  bronchus,  the  right  lung  is  often  involved  before  the  left. 

Cheesy  degeneration  of  an  area  of  pneumonic  exudate  may  occur, 
and  the  resulting  cheesy  pneumonia  frequently  leads  to  softening  and 
cavity-formation.  These  cavities  may  occur  in  any  part  of  the  lung, 
but  are  most  common  in  the  right  middle  and  upper  lobes,  and  usually 
communicate  with  a  bronchus.  Their  walls  are  irregular  and  grayish  in 
color;  blood-vessels  may  be  seen  crossing  them;  and  their  contents  are 
cheesy  or  necrotic  material. 

The  connective  tissue  of  the  lung  is  increased  in  cases  of  pulmonary 
tuberculosis  which  have  undergone  repeated  attacks  of  pneumonia, 
or  which  follow  empyema  of  long  standing.  In  such  cases  the  pleura 
also  is  thickened  and  may  be  covered  with  a  cheesy  exudate. 

Phthisis  as  it  iS'  seen  in  the  lungs  of  adult  subjects  is  not  met  with 
in  children  under  eight  or  ten  years  of  age. 

The  bronchial  lymph-nodes  in  cases  of  pulmonary  tuberculosis  are 
involved  in  the  tuberculous  inflammation  in  about  97  per  cent,  of  the 
cases.  This  is  contrary  to  A.  Ghon  who  holds  that  the  tubercle  bacil- 
lus does  not  pass  through  the  lungs  without  leaving  a  lesion  there.  The 
nodes  are  enlarged,  and  on  section  show  all  stages  of  tuberculosis,  from 
discrete  tubercles  with  small  cheesy  centers  to  cheesy  degeneration  of 
the  entire  node.  Softening  or  suppuration  is  very  common,  while 
calcareous  degeneration  of  a  tuberculous  focus  in  a  lymph-node  is 
infrequently  seen  in  infants,  but  is  less  rare  in  children  over  two  years 
of  age.  The  bronchial  and  mediastinal  lymph-nodes  may  be  so  much 
enlarged  as  to  afford  dulness  on  percussion  and  occasion  respiratory 
difficulty  from  pressure. 

Symptoms. — In  infants  and  very  young  children  there  is  no  char- 
acteristic symptomatology.  This  seems  strange  in  a  disease  of  such 
gravity.  Even  in  the  miliary  type,  where  we  have  been  taught  to  ex- 
pect high  temperature,  rapid  respiration,  and  other  severe  toxic  symp- 
toms, such  symptoms  do  not  always  exist.  The  signs  correspond  to 
those  of  bronchopneumonia — fever,  101°  to  104°F.,  rapidity  of  respira- 
tion,  cough,  and  the  chest  signs  peculiar  to  catarrhal  pneumonia. 


362  THE    PRACTICE    OF    PEDIATRICS 

There  may  be  only  cough  and  the  evidence  of  a  generahzed  bronchitis. 
The  temperature  range  is  not  characteristic,  and  may  not  differ  from 
that  of  bronchopneumonia. 

A  suspicious  symptom  in  an  infant  is  steady  emaciation  out  of  pro- 
portion to  the  other  positive  evidences  of  disease.  The  child  takes 
food  well,  sleeps  well,  and  is  comfortable.  There  may  be  a  slight  eleva- 
tion of  the  temperature  or  no  elevation  throughout  the  illness — in  fact, 
I  have  known  the  temperature  to  run  a  subnormal  course. 

In  older  children  after  the  third  year  the  disease  manifests  itself 
by  more  distinct  signs,  such  as  emaciation,  loss  of  appetite,  fatigue  on 
slight  exertion,  and  perhaps  night-sweats.  There  is,  moreover,  a  trou- 
blesome dry  cough  with  little  expectoration.  Elevation  of  tempera- 
ture in  older  children  is  an  invariable  symptom.  It  may  not  be  high, 
however,  perhaps  not  above  102°F.  in  the  evening.  The  child  com- 
plains of  chilliness  and  soon  shows  signs  of  anemia.  Pain  is  unusual, 
and  hemoptysis  rarely  occurs. 

In  the  miliary  type  in  older  children  the  symptoms  are  also  active, 
particularly  the  temperature,  which  will  range  very  high, — 103°  to 
105°F., — or  it  may  be  low  in  the  morning  and  high  at  night.  The  res- 
piration and  the  pulse  are  rapid.  Cough  is  not  a  prominent  symptom. 
There  is  rapid  loss  in  weight. 

It  will  be  observed  that  the  symptoms  may  aid  us  but  little.  The 
diagnosis  is  to  be  made  with  laboratory  aid. 

Diagnosis. — For  the  positive  diagnosis  of  tuberculosis  in  children 
the  presence  of  the  tubercle  bacilli  must  be  proved.  The  examination 
of  the  lungs,  except  by  showing  the  existence  of  a  cavity,  aids  us  but 
little,  for,  in  the  miliary  type,  there  may  be  tuberculosis  without  chest 
signs.  The  various  lung  changes  which  may  be  evident  on  examina- 
tion in  no  way  differ  from  those  which  may  be  found  in  acute  or  chronic 
bronchopneumonia.  Accompanying  tuberculosis,  moreover,  there 
may  be  a  bronchial  catarrh,  which  in  no  way  differs  in  its  manifesta- 
tions from  that  of  simple  generalized  bronchitis. 

A  positive  von  Pirquet  test  (p.  702)  is  strong  corroborative  evidence 
of  tuberculosis  in  young  infants.  The  presence  of  fine  crepitant  rales 
localized  over  the  right  middle  lobe  (front)  means  a  localized  tuber- 
culous process,  the  bacilli  being  conveyed  by  the  lymphatic  channels 
extending  from  the  bronchial  glands  to  the  spaces  between  the  lobes, 
middle  and  upper.  I  have  seen  the  value  of  this  sign  proved  in  a  large 
number  of  cases.  In  the  case  of  older  children  the  test,  while  positive, 
may  be  misleading,  as  the  tuberculosis  may  be  a  latent  process  or  entirely 
healed,  and  have  no  bearing  on  the  immediate  illness. 

After  the  fourth  or  fifth  year  the  diagnosis  is  seldom  beset  with 
the  difficulties  that  surround  the  infant.  At  the  later  period  of  life 
localized  signs  of  bronchitis,  or  partial  or  complete  consolidation  with 
dulness,  may  be  manifest.  Further,  children  at  this  age  expectorate, 
so  that  collection  of  the  sputum  is  easily  accomplished. 

Methods  of  Obtaining  Sputum. — In  dealing  with  infants  who  do  not 
expectorate,  a  satisfactory  method  of  obtaining  the  bronchial  secretion 


PULMONARY    TUBERCULOSIS  363 

is  to  pass  a  sterile  catheter  in  the  child's  larynx.     This  excites  coughing, 
the  secretion  is  brought  up  through  the  larynx  and  adheres  to  the  tube. 

Another  method  which  may  be  used  consists  in  irritating  the 
pharynx  with  a  small  piece  of  sterile  gauze  grasped  in  an  artery  clamp. 
As  a  result  of  the  coughing  thus  induced  the  secretion  from  the  trachea 
will  be  deposited  on  the  gauze.  Several  tests  may  be  necessary  before 
the  bacilli  are  discovered. 

Bacilli  in  the  Stool. — To  search  for  bacilli  in  the  stool  is  not  a  very 
satisfactory  procedure,  and  is  not  necessary,  in  view  of  the  success 
attending  the  above  methods  of  securing  material  for  examination.  In 
suspicious  cases  in  which  the  sputum  examination  fails  to  reveal  the 
bacillus  the  stools  should  be  examined. 

Prognosis. — The  prognosis  for  infants  is  very  unfavorable.  Never- 
theless in  infants,  healed  tubercular  foci  are  occasionally  found  at 
autopsy.  A  child  eighteen  months  of  age  who  died  of  diphtheria  had 
a  large  encysted  calcareous  tubercular  nodule  in  the  left  lung,  1  inch  by 
13>'^'  inches  in  size.  Likewise  the  bronchial  glands  may  show  evidences 
of  previous  disease.  In  view  of  the  large  percentage  (over  60  per 
cent.)  of  positive  reactions  to  the  von  Pirquet  skin  test  in  children 
past  ten  years  of  age,  it  would  seem  that  there  are  many  more  cured 
cases  in  children  than  has  heretofore  been  appreciated.  After  the 
fifth  year,  if  the  case  is  seen  reasonably  early,  if  the  child  has  a  fair 
resistance,  and  if  the  management  can  be  suitably  carried  out,  the 
prognosis  is  very  good  indeed.  I  have  had  a  recovery  from  pulmonary 
tuberculosis  in  a  child  of  four  years.  The  prognosis  is  further  favorable 
if  the  infection  is  primary.  If  there  is  a  lighting  up  of  an  old  tubercu- 
lar lesion  in  the  bronchial  glands  or  elsewhere,  the  prognosis  is  much 
less  favorable.  I  have  repeatedly  had  recoveries  in  New  York  City  in 
primary  cases  in  children  who  could  not  be  sent  away. 

Associated  Lesions. — The  invasion  of  the  tubercle  bacillus  usually 
means  the  involvement  of  more  than  one  organ  or  portion  of  the  body. 

The  Liver. — An  autopsy  in  a  case  of  pulmonary  tuberculd.sis  wall 
very  frequently  show,  in  addition  to  the  evidences  of  the  disease  in  the 
lung  and  pleura,  that  the  liver  is  involved  to  the  extent  of  showing  a 
generous  distribution  of  tubercle  bacilli  in  its  surface  and  in  the  liver 
substance. 

The  Spleen. — It  is  rare,  in  making  a  postmortem  examination  in 
pulmonary  tuberculosis,  not  to  find  the  spleen  the  seat  of  the  disease. 
Both  the  surface  and  the  splenic  tissue  may  be  filled  with  tubercular 
deposits. 

The  Heart. — Tuberculosis  of  the  heart  muscles  is  very  unusual. 
A  few  cases  have  been  reported.  The  pericardium  is  occasionally  the 
seat  of  a  few  tubercles.  They  are  usually  found  when  there  is  an  ex- 
tensive general  tuberculosis.  Their  presence  does  not  constitute  tu- 
berculosis of  the  pericardium. 

Stomach. —  Tuberculosis  of  the  stomach  is  of  very  rare  occur- 
rence. Hale  reports  having  seen  but  five  cases  in  his  large  autopsy 
experience. 


364  THE    PRACTICE    OF    PEDIATRICS 

hitestines. — Infection  of  the  intestinal  mucosa  without  further  ab- 
dominal involvement  is  occasionally  seen  at  autopsy. 

The  Kidney. — The  kidney  is  very  frequently  the  seat  of  tuberculo- 
sis. About  25  per  cent,  of  my  cases  have  shown  such  lesions.  They 
are  usually  of  the  miliary  type,  scattered  over  the  surface,  with  a  few  in 
the  kidney  substance. 

Tuberculosis  of  the  larynx  in  children  is  of  very  unusual  occurrence. 
Demme  reported  a  case  in  a  child  four  and  one-half  years  old  (Koplik). 

The  pancreas,  thymus  gland,  and  'peritoneum  are  rarely  at  autopsy 
found  to  be  the  seat  of  a  few  miliary  tubercles. 

Tuberculosis  of  the  cervical  lymph-glands,  hrain,  mesenteric  glands, 
peritoneum,  and  abdomen  will  be  discussed  in  separate  chapters. 

Treatment. — Climate. — For  those  who  are  so  situated  financially  as 
to  have  the  advantages  of  an  equable  climate,  a  change  of  residence 
or  sanitarium  treatment  should  be  provided.  A  dry  climate  of  equable 
temperature  that  will  allow  the  tuberculous  child  to  spend  the  greatest 
number  of  hours  in  the  open  air  is  best.  The  climate  of  southern  New 
Mexico  and  Arizona  is  exceptional  for  these  cases.  I  have  had  children 
do  well  in  the  Adirondacks  and  in  Sullivan  County,  New  York,  but  the 
severity  of  the  winter  makes  these  localities  less  desirable. 

Diet. — Equally  important,  if  not  more  so  than  climate,  is  the  nutri- 
tion of  the  patient.  This  must  be  raised  to  the  highest  possible  stand- 
ard, but  there  should  be  no  overfeeding,  such  procedure  being  of  no 
value  in  any  disease  in  the  young.  My  patients  have  improved  most 
on  a  high-proteid  diet  of  milk,  meat,  and  eggs,  and  a  high  proteid  cereal, 
such  as  oatmeal,  and  the  legumes — dried  peas,  beans,  and  lentils,  which 
are  given  in  the  form  of  a  puree.  I  have  found  it  advisable  not  to  in- 
sist that  a  definite  amount  of  food  be  given  in  twenty-four  hours.  The 
mother  or  nurse  is  to  be  told,  however,  that  these  foods,  prepared  in 
different  ways  so  that  the  child  will  not  tire  of  them,  are  to  form  a  con- 
siderable part  of  the  diet.  Green  vegetables,  fruits,  and  plain  desserts 
should  be  given  for  the  sake  of  variety  and  to  stimulate  the  appetite. 
When  three  meals  a  day  are  given,  with,  perhaps,  a  glass  of  milk  in  the 
middle  of  the  afternoon,  I  have  been  able  to  maintain  better  nutrition 
than  with  more  frequent  feedings.  Forced  feeding  in  children  often 
defeats  its  own  purpose  by  producing  disgust  for  or  intolerance  of  food. 
The  child  should  be  fed  on  nutritious  food,  for  which  an  appetite  must 
be  developed ;  for,  inasmuch  as  recovery  is  dependent  largely  upon  nu- 
trition, the  question  of  appetite  and  food  capacity  is  of  paramount 
importance.  Candy,  sweet  crackers,  and  other  harmful  articles 
should  not  be  allowed.  In  order  to  satisfy  the  candy  craving,  a  small 
quantity  of  sweet  chocolate  may  be  given  after  the  noonday  meal. 
The  best  appetizers  that  we  can  furnish  the  child  are  reasonable  exer- 
cise, entertainment  and  play  that  do  not  fatigue,  and  fresh  air  in 
abundance.  Upon  our  ability  to  meet  these  requirements,  depends,  to 
a  large  degree,  the  outcome  of  the  case. 

The  majority  of  the  children  with  pulmonary  tuberculosis  cannot 
be  sent  to  sanitariums  or  to  health  resorts.     The  patients  must  be 


PULMONARY    TUBERCULOSIS  365 

treated  in  their  homes.  This  I  have  done  successfully  in  New  York 
City  even  among  the  tenement  population.  The  basic  principles  of 
management  comprise  a  properly  directed  life,  good  food,  and  fresh 
air.  These  are  the  weapons  for  fighting  the  enemy,  regardless  of 
whether  the  residence  is  among  the  rich  or  poor,  in  town  or  in  country. 
It  is,  however,  among  the  tenement  population  that  we  experience  the 
greatest  difficulty.  To  tell  these  people  how  the  child  is  to  be  fed  is  not 
enough.  The  feeding  as  directed  entails  considerable  expense,  which 
the  parents  may  not  be  able  to  meet.  If  after  personal  investigation, 
which  should  be  made  in  every  case,  it  is  demonstrated  that  proper 
nutrition  or  suitable  clothing  is  impossible,  I  explain  the  situation  to 
some  charitably  inclined  person  of  means,  and  have  yet  to  know  of  an 
instance  in  which  clothing  and  a  small  but  sufficient  weekly  food-allow- 
ance were  not  forthcoming.  To  the  best  of  my  knowledge  the  child 
himself  has  always  had  the  benefit  of  the  charity,  and  I  have  investi- 
gated such  cases  closel3\  An  allowance  of  25  cents  a  day  for  fresh 
meat  and  milk  has  often  furnished  what  was  required  to  bring  the  case 
to  a  favorable  termination.  The  uselessness  of  much  of  our  medical 
advice  to  the  poor  would,  on  slight  reflection  or  a  little  investigation,  be 
apparent.  Directions  are  too  often  given  for  the  care  of  the  sick  which 
are  absolutely  impossible  of  fulfilment. 

Hygiene. — In  addition  to  the  diet  above  outlined,  the  advantages 
of  an  outdoor  life,  and  the  means  by  which  fresh  air  may  be  obtained 
all  the  year  round,  should  be  fully  explained.  Any  simple  direction  as 
to  what  may  appear  to  be  a  radical  procedure  is  rarely  carried  out  with- 
out a  rational  explanation  of  its  necessity.  During  the  daytime  the 
child  should  be  kept  outdoors.  Close,  tightly  sealed  sleeping  apart- 
ments at  night,  however,  will  undo  the  good  of  the  outdoor  life  during 
the  day.  The  mother  should  be  told  to  have  the  child  sleep  alone  in 
the  largest  room  of  the  apartment,  and  always  in  a  room  in  which  the 
windows  are  opened.  This  is  usually  possible.  A  sponge-bath  or  tub- 
bath  should  be  given  at  bedtime,  followed  by  brisk  rubbing  with  a 
towel.  If  there  is  much  emaciation,  an  olive-oil  or  goose-oil  inunction 
should  follow  the  salt  bath. 

Sometimes  these  directions  are  followed  implicitly;  at  other  times 
they  are  forgotten.  It  is  astonishing,  however,  what  rapid  improve- 
ment will  follow  when  a  tuberculous  child  of  tenements  is  given  the 
benefit  of  fresh  air,  day  and  night,  with  suitable  food  and  cleanliness, 
even  though  the  conditions  are  those  of  New  York  City.  Among  the 
more  fortunate  classes  the  same  method  of  treatment,  of  course,  with 
a  more  satisfactory  application,  is  to  be  carried  out.  Among  the  well- 
to-do,  however,  we  see  fewer  cases. 

Tonics. — The  usefulness  of  drugs  depends  to  a  large  degree  upon 
an  increase  of  food  capacity  which  their  use  may  cause.  Any  of  the 
prescriptions  written  below  may  be  used  alternately  with  cod-liver  oil 
and  malt,  each  being  given  for  five  days.  For  a  child  from  seven  to 
twelve  years  of  age  the  following  are  useful  restoratives  and  appetizers : 


366  THE    PRACTICE    OF    PEDIATRICS 

I^     Tincturae  nucis  vomicae gtt.  Ixxij 

Saccharini gr.  iss 

Aquse q.  s.  ad  §iv 

M.  Sig. — One  teaspoonful  every  two  hours.     (Six  doses  daily.) 

^    Ferri  et  quininse  citratis gr.  xxiv 

Vini  xerici §  iv 

M.  Sig. — One  teaspoonful  in  water  three  times  a  day  after  meals. 

I^    Tincturae  nucis  vomicae .gtt.  Ixiv 

Extraeti  ferri  pomati gr.  vj 

Quininse  bisulphatis 3j 

M.  ft.  capsulae  no.  xxx. 

Sig. — One  after  each  meal. 

If  night-sweats  are  present,  from  J-^oo  to  ^eo  grain  of  atropin  at 
bedtime  will  often  furnish  relief. 

Care  of  the  Sputum. — Various  devices  for  collecting  the  sputum  may 
be  obtained  in  the  shops.  A  cheap  and  effective  method  is  the  use  of 
a  Japanese  handkerchief,  which,  when  used,  is  at  once  placed  in  a^ 
paper  bag,  the  bag  and  its  contents  being  burned  at  the  close  of  the 
day.  The  dangers  of  infecting  others  should  be  fully  explained  to  those 
in  charge  of  the  patient,  kissing  and  fondling  being  forbidden. 

HELIOTHERAPY 

Heliotherapy  or  the  treatment  of  bodily  ills  by  exposure  to  the 
sun's  rays  has  been  utilized  for  curative  purposes  many  centuries.  In 
the  Swiss  Alps,  Rollier  and  Bernhard  were  the  first  to  take  up  helio- 
therapy in  a  scientific  manner  for  the  definite  end  of  curing  tubercu- 
losis. The  method  is  very  simple  and  consists  in  exposing  the  body 
to  the  direct  rays  of  the  sun  for  a  given  time. 

Most  satisfactory  results  are  reported  by  the  above  authors,  par- 
ticularly in  cases  of  surgical  or  bone  tuberculosis.  This  method  of 
treatment  of  tuberculosis  has  been  carried  on  by  Dr.  Gerald  Webb  of 
Colorado  Springs  and  the  procedure  is  described  as  follows:  Children 
can  be  exposed  naked  at  an  altitude  of  4000  to  5000  feet  when  snow  is 
on  the  ground  because  the  temperature  in  the  sun  may  be  as  high  as 
90°F.  or  even  120°F.  Patients  arriving  at  this  altitude  are  first  al- 
lowed to  become  acclimated  by  rest  indoors  for  a  few  days.  Thea 
they  are  placed  on  verandas  with  a  white  garment  covering  the  body. 

Exposures  to  the  sunlight  are  made  very  cautiously  and  gradually, 
fixed  rules  being  followed  no  matter  what  part  of  the  body  may  be 
effected  with  tuberculosis.  On  the  first  day,  the  feet  are  exposed  three 
or  four  times  at  hourly  intervals,  for  five  minutes  each  time. 

On  the  second  day,  the  bare  legs,  to  the  knees  are  exposed  in  a 
similar  manner,  and  the  feet  are  exposed  three  times  for  ten  minutes 
each.  On  the  third  day,  these  exposures  are  increased  by  five  minutes, 
three  times  daily,  and  on  the  fourth  day,  the  thighs  are  included.  On 
the  fifth  day  the  abdomen  and  chest  respectively  are  exposed.  The 
pulse  and  temperature  variations  are  used  in  guiding  the  treatment, 
and,  in  certain  individuals,  variations  in  the  sun  treatment  are  made^ 


HELIOTHERAPY  367 

By  this  method  in  summer  or  winter  patients  can  remain  from  four 
to  six  hours  bathing  in  the  sun. 

Naturally  other  surgical  methods  are  not  neglected.  Splints, 
braces,  and  the  like  are  employed,  when  necessary  to  limit  motion  in 
diseased  joints.  The  appliances  are  made  as  light  and  as  open  as 
possible.  Open  wounds  when  not  being  sunned,  are  dressed  with  gauze 
soaked  in  alcohol.  Such  "open"  cases  are  found  more  refractory  to 
the  treatment  than  ''closed"  cases. 

Certain  blood  changes  have  been  noted,  such  as  an  increase  in  the 
number  of  the  red  blood  corpuscles.  Some  observers,  too,  have 
claimed  that  the  lymphocyte  blood  cells — known  to  be  antagonistic  to 
the  tubercle  bacillus — are  increased  by  heliotherapy.  We  have  not 
been  able  to  confirm  this  in  our  work. 

We  have  carried  out  this  method  of  treatment  for  three  years  at 
Colorado  Springs,  but,  while  finding  it  to  be  of  much  benefit  to  our 
patients,  with  either  bone,  joint  or  glandular  tuberculosis  (surgical 
tuberculosis)  as  well  as  to  those  patients  with  pulmonary  tuberculosis, 
we  are  not  yet  able  to  share  the  same  high  degree  of  optimism  for  the 
method  which  is  held  by  Rollier. 

We  feel  it  wise  to  warn  patients  against  the  careless  employment 
of  sun  baths  without  proper  medical  control  as  harm  can  be  done  by 
them.  The  head  should  be  protected,  especially  at  first,  by  a  hght 
hat,  and  in  the  case  of  adults,  Rollier  sometimes  advises  the  covering 
of  the  heart  with  a  wet  compress. 

My  own  limited  observations  of  the  sun  treatment  for  tuberculosis 
have  not  been  such  as  to  warrant  any  gr^at  enthusiasm  for  this  method 
of  treatment. 


IX.  DISEASES  OF  THE  HEART 

DIAGNOSIS  IN  DISEASES  OF  THE  HEART 

Auscultation. — In  the  diagnosis  of  the  different  cardiac  lesions  in 
children  auscultation  is  by  far  the  most  useful  means  at  our  command. 
For  adults  the  physician  employs  auscultation,  either  with  the  naked 
ear  or  with  the  stethoscope,  at  the  following  chest  areas : 
The  aortic  area. 
The  pulmonary  area. 
The  tricuspid  area. 
The  mitral  area. 

In  children  tricuspid  disease  is  of  most  infrequent  occurrence. 
The  pulmonary  valves  are  involved  only  in  congenital  heart  disease. 
In  the  routine  examination  for  heart  lesions  in  children  the  findings 
are  simplified  by  the  fact  that  aortic  and  mitral  valve  lesions  are  those 
encountered  in  an  immense  majority  of  the  cases. 

Owing  to  the  difference  in  the  position  of  the  heart  of  the  child  as 
compared  with  that  of  the  adult,  the  various  sound  areas  also  differ, 
and  they  vary  at  the  different  periods  of  childhood  in  accordance  with 
the  changing  position  of  the  heart. 

Before  the  sixth  year  the  mitral  area  corresponds  with  the  apex- 
beat  at  a  point  in  the  nipple-line,  or  not  more  than  Y^  inch  without 
the  nipple-line,  in  the  fourth  interspace. 

The  aortic  area  is  slightly  to  the  right  of  the  sternum  in  older  chil- 
dren; in  the  very  young,  over  the  sternum  or  at  its  immediate  right 
border,  at  the  level  of  the  second  or  third  interspace,  varying  with  the 
age  of  the  child. 

The  pulmonic  area  is  on  the  same  plane  at  the  left  border  of  the 
sternum. 

At  the  end  of  the  sternum,  slightly  to  the  left,  is  the  tricuspid  area. 

It  is  by  no  means  claimed  that  sound  areas  indicate  the  position 
of  the  valves,  but  we  know,  from  combined  clinical  and  autopsy  find- 
ings in  children,  that  murmurs  indicating  lesions  of  the  respective 
valves  are  best  heard  at  these  areas. 

The  Normal  Sounds. — TJhe  normal  heart-sounds  are  not  easily 
described.  The  normal  cardiac  cycle  is  made  up  of  the  Jirsf  and  second 
heart-sounds.  Listening  at  the  apex  or  slightly  above,  one  hears  at  the 
time  of  the  impulse  the  low-pitched,  dull  first  sound,  followed  by  the 
so-called  second  sound,  which  is  short  and  higher  pitched,  and  is  sup- 
posed to  be  due  to  closure  of  the  semilunar  valves. 

There  is  much  divergence  of  opinion  as  to  the  cause  of  the  first 
sound.  Most  diagnosticians  believe  that  it  is  due  to  the  contraction 
of  the  heart  muscles,  associated  with  the  sudden  closure  of  the  mitral 
valves. 

368 


DIAGNOSIS   IN   DISEASES    OF   THE    HEART  369 

The  heart-sounds  vary  considerably,  depending  upon  the  age  of  the 
patient;  thus,  in  the  infant  both  sounds  are  short  and  high  pitched, 
and  the  muscle  sounds  which  appear  later  in  life,  while  present,  are 
not  prominent. 

There  is  rarely  difficulty  in  differentiating  the  two  sounds  in  the 
young.  The  second  sound  is  heard  loudest  over  the  base  of  the  heart 
at  points  corresponding  more  or  less  closely  to  the  pulmonic  and  aortic 
areas.  In  the  event  of  difficulty  in  differentiation,  the  first  sound 
should  be  sought  at  the  apex.  On  gradually  moving  the  stethoscope 
upward,  the  first  sound  will  gradually  become  fainter  and  as  the  base 
of  the  heart  is  approached  the  second  sound  will  be  heard  much  more 
distinctly  and  loudest  in  the  areas  referred  to. 

The  points  of  maximum  intensity  and  areas  of  transmission  of 
heart-sounds  in  children  can  not  be  arbitrarily  laid  down.  In  a  gen- 
eral way  the  landmarks  can  be  indicated,  and  in  most  instances  will 
stand. 

In  diagnosing  cardiac  disease  in  children  we  have  to  consider  the 
age  of  the  patient  with  particular  reference  to  the  size  and  position 
of  the  heart,  whether  the  chest-wall  is  thin  and  muscular,  or  fat,  and 
whether  the  child  is  crying  or  quiet.  All  cardiac  sounds  in  the  young 
are  proportionately  much  louder  than  in  adults.  In  delicate  children 
the  sounds  vary  greatly  from  those  heard  in  the  strong  and  robust.  A 
first  sound,  characterized  by  a  muffling  or  absence  of  clearness,  is  very 
frequently  heard  in  delicate  children.  After  an  illness  in  a  strong 
child  this  peculiar  quality  is  very  apparent,  and  is  without  doubt  due 
to  muscular  insufficiency  induced  by  degenerative  changes  which  in 
most  cases  are  temporary  in  character. 

The  changed  first  sound  is  often  interpreted  and  treated  as  an  evi- 
dence of  endocarditis.  In  heart  failure  in  serious  diseases,  the  muscle 
element  of  the  first  sound  gradually  disappears  so  that  this  sound  be- 
comes short  and  snappy  in  quality,  due  to  a  degeneration  of  the  heart 
muscle.  The  weak  muscle  sound  tends  to  exaggerate  the  sound  pro- 
duced by  the  valve  closure. 

The  second  sound  is  caused  by  the  closure  of  the  semilunar  valves, 
and  as  there  are  two  sets  of  these  valves,  the  aortic  and  pulmonary, 
the  aortic  second  sound  (in  older  children)  is  heard  in  the  aortic  area 
and  the  pulmonic  second  sound  in  the  pulmonary  area. 

In  babies  and  very  young  children  a  differentiation  of  the  aortic 
and  pulmonic  second  sounds  is  unquestionably  difficult.  (Imagina- 
tion, however,  carries  many  diagnosticians  over  obstacles.)  The  sec- 
ond sound  is  always  accentuated  in  conditions  in  which  the  cardiac 
vigor  is  temporarily  or  permanently  impaired,  as  in  myocarditis  with 
hypertrophy  and  dilatation  of  the  left  ventricle. 

Inspection. — Inspection  alone  is  of  little  value  in  cardiac  examina- 
tion. One  learns  nothing  by  inspection  that  may  not  be  discovered 
through  palpation,  percussion,  and  auscultation.  In  acute  cardiac 
disease  in  which  there  is  often  a  decided  overaction  of  the  heart,  a 
decided  undulating  movement  of  the  entire  left  chest  anteriorly  will 
24 


370  THE  PRACTICE  OF  PEDIATRICS 

be  observed.  This  usually  occurs  when  there  is  much  dilatation  or 
hypertrophy  of  the  left  ventricle. 

Inspection  may  reveal  a  retraction  of  the  chest-wall  at  the  apex 
between  the  fourth  and  fifth  interspaces.  This  closing-in  is  due  to 
adhesions  (the  result  of  a  former  pericarditis)  between  the  heart,  the 
pericardium,  and  the  chest-wall. 

Palpation. — Palpation  is  useful  in  determining  the  position  of  the 
apex-beat,  in  judging  of  the  force  of  the  cardiac  impulse,  and  in  the 
detection  of  a  thrill.  The  pericardial  friction-rub  and  the  heart 
rhythm  may  likewise  be  determined  in  this  way. 

Percussion. — For  this  examination,  I  prefer  the  upright  position. 
Percussion  is  chiefly  of  value  in  determining  the  size  of  the  heart. 
Hypertrophy  or  dilatation  of  both  the  right  and  left  heart  may  be 
fairly  accurately  determined.  This  method  is  also  of  value  in  deter- 
mining the  amount  of  fluid  in  the  pericardial  sac. 

The  normal  right  limit  of  absolute  dulness  for  the  heart  may  be 
taken  as  the  left  sternal  border.  The  midsternal  line  supplies  the 
boundary  for  relative  dulness.  The  left  limit  of  dulness  corresponds 
to  a  perpendicular  line  drawn  slightly  without  the  apex-beat. 

The  area  of  dulness  will  vary  considerably  in  health.  The  younger 
the  child,  the  further  to  the  left  will  be  located  the  border  of  cardiac 
dulness.  This  limit  is  best  determined  by  percussing  from  a  point  in 
the  anterior  axillary  line  toward  the  right,  in  the  fourth  interspace. 

HEART  MURMURS 

There  are  two  gross  divisions  of  heart  murmurs :  Organic  or  valvular ^ 
inorganic  or  functional  {non-valvular) . 

Organic  murmurs  are  the  result  of  a  change  in  the  heart  structure 
due  to  a  congenital  malformation  or  to  deformities  resulting  from  dis- 
eased processes  which  produce  a  thickening,  contraction,  shortening^ 
or  narrowing  of  the  valves  involved. 

An  enlargement  of  the  orifice  (e.  g.,  the  mitral  or  aortic  orifice)  may 
also  cause  a  murmur  due  to  the  resulting  incomplete  closure  of  the 
valves. 

Regurgitant  Murmur. — When  the  valves  fail  to  close,  a  murmur  is 
caused  by  the  regurgitation  of  the  blood  back  through  the  opening. 
If  the  valves  are  roughened,  the  intensity  of  the  murmur  is  the  greater. 

Stenotic  Murmur. — When  the  blood  is  impeded  in  its  passage 
through  the  heart  as  a  result  of  a  narrowing  of  the  opening  or  roughen- 
ing of  the  valves,  a  murmur  of  stenosis  is  the  outcome. 

Organic  heart  murmurs  are  classified  as  follows,  depending  upon 
the  time  of  their  occurrence  in  the  cardiac  cycle: 
Systolic. 
Diastolic. 
Presystolic. 

From  the  association  of  the  murmur  with  one  or  another  of  the 
different  phases  of  the  cardiac  cycle  we  determine  the  location  and 
nature  of  the  lesion  at  hand. 


HEART   MURMURS  371 

Location  of  Lesions.— In  examination  of  the  heart  in  order  to 
locate  a  lesion  by  the  murmur  we  must  determine  when  it  occurs  in 
the  cardiac  cycle,  its  point  of  maximum  intensity,  and  its  area  of 
diffusion. 

Acquired  Lesions. — In  children  acquired  valvular  lesions  will  almost 
invariably  be  found  to  involve  the  left  heart,  the  mitral  valves  being 
by  far  the  most  liable  to  disease. 

Mitral  insufficiency  takes  first  place  in  the  order  of  frequency  of 
valvular  lesions.  Mitral  stenosis  is  evidently  present  in  about  10  per 
cent,  of  the  cases  of  insufficiency.  Lesions  of  the  aortic  valves  are 
fortunately  much  rarer.  The  ratio  of  mitral  to  aortic  disease  is  about 
15  to  1. 

Table  Demonstrating  Location  and  Character  of  Lesions  Based  Upon  the 
Adventitious  Heart-sounds  or  Murmurs 

Systolic  Diastolic  Pbeststolic 

Mitral  regurgitation.  Aortic  regurgitation.  Mitral  stenosis. 

Tricuspid  regurgitation.      Pulmonary  regurgitation.     Pulmonary  stenosis. 
Pulmonary  stenosis; 
Aortic  stenosis. 

Pulmonary  stenosis  occurs  only  as  the  result  of  congenital  lesions, 
and  tricuspid  lesions  in  children  are  only  observed  very  late  in  severe 
cardiac  disease,  as  a  result  or  accompaniment  of  right  heart  failure. 
In  the  absence  of  these  etiologic  conditions  a  systolic  murmur  in  a 
child  must  therefore  be  attributed  to  mitral  regurgitation  of  aortic 
stenosis.  Moreover,  for  the  reasons  explained,  a  diastolic  murmur 
means  aortic  regurgitation,  and  a  presystolic  murmur,  mitral  stenosis.. 

Acquired  lesions  in  children  will,  therefore,  permit  of  the  following 
grouping. 

Ststolic  Diastolic  Preststolic 

Mitral  regurgitation.  Aortic  regurgitation.  Mitral  stenosis. 

Aortic  stenosis. 

Keeping  the  time  of  the  murmur  in  mind,  we  thus  have  a  rfteans 
of  readily  locating  the  lesions. 

Mitral  regurgitation  is  due  to  shortening  or  adhesions  of  the  mitral 
valves,  sufficient  to  prevent  proper  closure  of  the  leaflets.  The  valvu- 
lar defects  are  the  result  of  a  previous  acute  or  chronic  endocarditis. 
The  murmur  of  mitral  regurgitation  is  heard  loudest  in  the  apex  region, 
over  the  so-called  mitral  area.  In  children,  because  of  their  thin  chest- 
walls,  this  murmur  has  a  wide  transmission.  The  particular  line  of 
transmission  is  upward  and  to  the  left  toward  the  axilla,  and  to  the 
back,  the  sound  being  loudest  at  the  angle  of  the  scapula  and  between 
the  scapula  and  the  vertebrae. 

Mitral  stenosis  (producing  a  presystolic  murmur)  is  due  to  a  narrow- 
ing or  partial  permanent  closure  of  the  mitral  orifice  as  the  result  of 
adhesions  which  bind  the  valves  together,  and  produce,  in  some  in- 
stances, the  so-called  funnel  or  button-hole  opening.  The  murmur  is 
heard  loudest  slightly  above  and  to  the  right  of  the  apex-beat.     In 


372  THE    PRACTICE    OF    PEDIATRICS 

point  of  time  it  precedes  the  systolic  or  first  sound  of  the  heart.  Not 
infrequently  the  murmur  merges  into  that  produced  by  the  mitral  re- 
gurgitation, completely  replacing  the  first  sound  of  the  heart.  The 
area  of  diffusion  is  quite  circumscribed. 

Mitral  lesions  which  have  existed  for  some  time  always  give  rise  to 
compensatory  hypertrophy,  with  corresponding  displacement  of  the 
apex-beat  to  the  left.  This  may  readily  be  determined  by  palpation 
and  percussion,  showing  the  degree  of  cardiac  enlargement. 

The  Thrill. — As  a  result  of  the  contracted  orifice  or  the  roughened 
valve  surf  aces,  vibrations  are  produced  in  the  blood-stream,  which,  when 
transmitted  to  the  chest  surface,  produce  a  corresponding  peculiar 
effect  upon  the  palpating  finger  or  hand  of  the  examiner.  This  sign  is 
known  as  a  thrill. 

Aortic  stenosis  produces  a  systolic  murmur  which  is  heard  loudest 
over  the  sternum  and  the  second  left  costal  interspace;  not  over  the 
second  right  interspace  or  to  the  right  of  the  sternum,  as  in  the  case  of 
adults.  The  murmur,  which  is  usually  harsh  and  grating  in  character, 
is  widely  transmitted  in  a  lateral  direction  and  also  into  the  carotids  of 
the  neck.  Autopsy  usually  shows  the  existence  of  adhesions  between 
the  semilunar  valves. 

In  comparatively  few  cases  a  thrill  may  be  felt  over  the  upper  portion 
of  the  chest  and  the  carotids.  In  a  girl  patient  eight  years  of  age 
there  is  a  most  exceptional  thrill  over  the  dilated  arch  of  the  aorta  and 
the  carotids. 

In  aortic  regurgitation  the  murmur  is  diastolic  in  time,  and  is  heard 
not  to  the  right  of  the  sternum,  but  sharply  against  the  left  border,  or 
over  the  extreme  left  of  the  sternum,  on  a  level  with  the  fourth  costal 
cartilage.  This  murmur  is  usually  associated  with  the  obstructive 
murmur,  and  is  due  to  a  failure  of  the  deformed  valves  to  close.  The 
area  of  diffusion  is  wide.  There  is  always  displacement  of  the  apex- 
beat  to  the  left.  It  is  the  condition  of  aortic  regurgitation,  preemi- 
nently, that  causes  visible  pulsation  of  the  carotids.  In  the  child  al- 
ready referred  to,  the  throbbing  was  so  pronounced  that  not  only  was 
the  head  and  body  shaken,  but  the  mother,  who  slept  with  the  patient, 
was  kept  awake  by  the  vibration  of  the  bed. 

Functional  Murmurs. — Functional  murmurs  are  most  frequently 
encountered  between  the  third  and  twelfth  years.  The  functional 
murmur  in  infants  or  very  young  children  will  almost  always  be  asso- 
ciated with  anemia.  This  is  not  invariably  the  case,  however,  but  a 
non-organic  murmur  at  this  age  may  be  the  result  of  a  very  severe 
illness  or  whooping  cough, — causing  a  temporary  dilatation. 

The  functional  murmur  is  systolic  in  time,  and  is  heard  loudest  at 
or  slightly  above  the  apex,  with  a  uniform,  circumscribed  area  of  diffu- 
sion which  extends  for  only  a  few  inches  in  any  direction.  In  character 
the  murmur  is  soft  and  blowing.  It  is  not  heard  at  the  back.  There 
is  no  associated  hypertrophy  or  dilatation  of  the  heart  or  evidence  of 
any  stasis  or  dropsy.  There  is  no  accentuation  of  the  second  sound. 
The  functional  murmur  is  not  at  all  unusual  in  rapidly  growing  chil- 


HEART   MURMURS  373 

dren  of  both  sexes.  The  presence  of  a  functional  diastoUc  murmur  in 
children  is  practically  unknown. 

Venous  Murmurs. — In  anemia  the  normal  venous  murmur  heard 
over  the  great  vessels  above  the  clavicle  and  posterior  to  the  sterno- 
cleido-mastoid  muscle  is  intensified  and  exceeds  its  normal  physiologic 
limits.  The  murmur  is  constant,  although  it  may  be  accentuated 
when  the  patient  stands  with  head  inclined  to  the  opposite  side.  The 
venous  murmur  is  to  be  distinguished  from  the  arterial  murmur  by 
the  fact  that  the  former  is  continuous  and  not  synchronous  with  the 
heart-beat. 

Etiology. — Anemia  probably  constitutes  the  most  frequent  cause, 
yet  functional  murmurs  are  heard  in  apparently  normal  children, 
existing  for  a  period  of  years  and  then  disappearing.  A  temporary 
murmur  will  often  be  heard  in  boys  after  violent  exercises  or  games  of 
competition  in  which  a  great  deal  of  physical  work  is  involved.  In 
girls  the  murmur  may  also  result  from  excessive  bicycle-riding  or  pro- 
longed rope-jumping.  In  the  spring  of  the  year,  after  hard  work  at  a 
school,  many  girls,  under  careful  examination,  will  show  a  slight  systolic 
murmur.  In  my  opinion  many  of  these  cases  are  due  to  a  dilatation 
of  the  left  heart,  producing  a  wider  auriculoventricular  orifice  than 
the  valves  can  completely  close,  with  the  result  that  there  is  a  moderate 
amount  of  leakage.  This,  in  time,  is  corrected  as  the  heart  muscle 
regains  its  normal  condition. 

Differential  Diagnosis. — The  chief  point  of  aid  in  differentiating  all 
murmurs,  whether  functional,  acquired,  or  congenital,  is  the  fact  that 
in  congenital  and  acquired  heart  disease  there  is  a  distinct  lesion,  and 
the  murmur,  as  can  be  readily  understood,  is,  therefore,  constant. 
When,  however,  the  murmur  is  due  to  causes  related  to  muscular  action 
or  blood  conditions,  variations  in  posture  or  changes  in  the  heart 
action,  dependent  upon  work,  will  produce  either  a  modification  of  the 
murmur  or  its  complete  disappearance.  Even  during  a  single  ex- 
amination a  murmur  of  this  nature  may  not  always  be  the  same. 

Illustrative  Case. — A  boy  patient,  aged  six  years,  has  a  soft,  blowing  systolic 
murmur,  which  presents  varying  degrees  of  intensity,  depending  upon  whether  he  is 
lying  down  or  sitting  up  or  whether  he  is  quiet  or  exercising.  I  have  known  this 
boy  since  birth.  The  murmur  appeared  when  he  was  two  years  old.  He  is,  and 
always  has  been,  the  picture  of  health.  The  murmur  is  gradually  becoming  less 
each  year  and  when  he  is  ten  years  old  will  probably  cease  to  exist.  An  older  sister 
gave  evidence  of  exactly  the  same  condition,  the  murmur  in  her  case  d'sappearing 
at  about  the  ninth  or  tenth  year.  The  murmurs  in  these  children  were  not  anemic 
or  cardiorespiratory. 

Cardiorespiratory  Murmur. — This  murmur  deserves  particular  men- 
tion for  the  reason  that  it  has  a  distinct  entity.  It  may  be  heard  in 
those  cases  in  which  the  margin  of  the  lung  covers  the  heart.  The  mur- 
mur is  usually  systolic.  It  is  heard  best  when  the  patient  is  standing 
and  leaning  forward,  and  at  the  end  of  inspiration  is  usually  loudest. 
This  murmur  has  no  clinical  signifiance,  and  is  of  interest  only  because 
it  may  be  confused  with  other  murmurs,  functional  or  organic. 


374  THE  PRACTICE  OF  PEDIATRICS 

Murmur  During  Development. — As  already  noted,  a  functional  mur- 
mur is  not  at  all  unusual  in  rapidly  growing  children. 

After  Acute  Illness. — Inasmuch  as  the  functional  murmur  which 
occasionally  occurs  with,  and  disappears  after,  an  acute  illness  is  in  all 
respects  similar  to  those  that  exist  for  several  years  and  are  later  out- 
grown, it  may  be  fair  to  assume  that,  in  both  instances,  the  same  cause 
is  operative,  and  that  this  factor,  in  all  probability,  is  a  moderate  re- 
gurgitation, due  perhaps  to  a  dilatation  of  the  mitral  orifice  preventing 
proper  closure  of  the  valves,  a  condition  temporary  in  both  types  of 
cases,  but  in  the  one  of  longer  duration  than  in  the  other. 

Treatment. — The  functional  murmur  requires  no  treatment.  But 
the  condition  causing  the  murmur  may  require  attention,  and  upon  this 
conclusion  the  treatment  must  rest. 

PERICARDITIS 

Pericarditis  is  an  inflammation  of  the  pericardium.  No  period  of 
life  appears  to  be  exempt.  My  youngest  patient  was  six  months  of  age. 
The  disease  occurs  most  frequently  between  the  third  and  the  twelfth 
years.  Cases  have  been  reported  by  different  authors  as  occurring  in 
fetal  life.  Pericarditis  is  the  result  of  an  infection  and  occurs  practi- 
cally always  as  a  secondary  disease  either  in  association  with  rheuma- 
tism or  as  a  result  of  the  invasion  of  pathogenic  bacteria  carried  through 
the  blood-stream  or  by  the  lymph  from  other  portions  of  the  body. 

Bacteriology. — The  bacterium  most  often  found  in  the  sero- 
fibrinous or  purulent  exudate  is  the  pneumococcus,  a  fact  which  is 
explained  by  the  frequency  of  pulmonary  lesions  as  the  primary  source 
of  the  infection  in  these  cases — 70  per  cent,  to  90  per  cent.  The 
streptococcus  or  the  staphylococcus  aureus  may  be  present;  and 
very  rarely  B.  influenzae  or  the  gonococcus  has  been  found  in  the  course 
of  septicemia  due  to  these  bacteria.  The  tubercle  bacillus,  as  the  cause 
of  fibrinous  or  purulent  pericarditis  in  children,  is  almost  unknown. 
Tuberculosis  is  more  apt  to  involve  the  external  surface  of  the  sac, 
owing  to  possible  extension  of  tuberculosis  of  the  lung. 

Poynton  has  found  the  diplococcus  of  rheumatism  in  the  plastic 
exudate  of  pericarditis  complicating  rheumatism. 

Pathology. — Pericarditis  possesses  as  wide  possibilities  as  pleuritis, 
and  the  pathologic  processes  are  quite  similar.  Thus,  there  may  be 
only  simple  dryness  of  the  lining  of  the  pericardial  sac,  or  a  com- 
plete filling  of  the  sac  with  serous  or  purulent  fluid.  Over  the  heart 
and  the  enveloping  membrane  only  thin  layers  of  fibrin  may  form;  or 
the  heart  and  pericardium  may  become  firmly  bound  together  by  layers 
and  bands  of  fibrinous  exudate.  Autopsies  on  purulent  cases  often 
show  the  heart  wrapped  in  the  meshy  fibrinous  exudate  to  such  a  de- 
gree that  the  muscle  surface  cannot  be  seen,  while  the  inner  surface  of 
the  pericardium  is  lined  with  a  granular  exudate  and  the  intervening 
space  is  filled  with  fluid  serum  or  pus.  On  showing  postgraduate 
students  such  specimens  I  have  witnessed  complete  failure  of  the  entire 


PERICARDITIS  375 

class  to  recognize  the  organ  before  them,  so  great  has  been  the  change 
from  the  normal  appearance. 

Symptoms. — Pericarditis  is  a  disease  which  stands  out  peculiarly 
because  of  the  wide  range  of  the  possible  symptoms.  Thus  a  case  of 
purulent  pericarditis  may  run  its  course  under  the  observation  of  excel- 
lent clinicians  and  not  be  recognized  until  the  autopsy,  or  the  condi- 
tion may  produce  symptoms  of  the  greatest  urgency  and  occasion  in- 
tense distress  to  the  patient.  It  is,  therefore,  impossible  to  lay  down 
a  symptomatology  for  the  disease  that  will  apply  to  all  cases.  Peri- 
carditis is  probably  more  frequently  overlooked  by  clinicians  than 
any  other  disease. 

An  important  symptom  indicating  pericarditis  is  rapid  respiration. 
Not  only  is  the  breathing  rapid,  as  in  pneumonia,  but  it  is  fairly  charac- 
teristic in  that  the  respirations  are  guarded.  The  patient  wears  an 
anxious  expression  and  appears  to  have  his  mind  centered  on  breathing. 
Carefully  guarded  inspiration  is  taken  and  careful  expiration  is  carried 
out.  At  the  same  time  the  respiration  is  hurried  and  short,  although 
not  precipitate.  This  cautious  breathing  is  due  to  the  feeling  of  de- 
cided discomfort,  constriction,  and  even  pain  which  accompanies  the 
chest  expansion.  The  respiration  is  somewhat  similar  to  that  of  acute 
pleurisy.  The  individual  is  not  sure  that  he  will  be  able  to  complete 
respiration,  and  perhaps  feels  obliged  to  cut  it  short. 

The  very  rapid  heart  action  is  the  most  reliable  symptom  of  the  dis- 
ease, often  exceeding  in  apparent  severity  all  the  other  symptoms.  I 
have  repeatedly  seen  patients  from  eight  to  ten  years  of  age  with  a 
temperature  ranging  only  about  100°F.,  with  a  pulse-rate  from  130  to 
150  or  higher. 

Cyanosis  is  present.  The  expression  is  anxious.  In  my  urgent 
cases  a  prominent  symptom  has  been  extreme  restlessness.  Discom- 
fort, pain,  and  a  feeling  of  tension  over  the  precordium  are  at  times 
complained  of.  In  other  cases  with  apparently  quite  pronounced 
lesions  there  is  Httle  or  no  discomfort. 

Diagnosis. — Pericarditis  with  rare  exceptions  is  secondary  to  in- 
fection elsewhere.  Thus  in  older  children  after  the  third  year  it  is 
usually  associated  with  endocarditis  of  rheumatic  origin.  I  have  seen  a 
great  many  cases  with  this  combination.  In  every  case  of  endocarditis 
the  physician  should  especially  investigate  the  cause  of  exceptional 
rapidity  of  breathing  and  a  rapid  pulse.  In  younger  children  pericar- 
ditis is  associated  with  pneumonia  and  empyema  with  greater  fre- 
quency than  with  any  other  disease. 

Physical  Signs. — The  first  evidence  of  pericardial  inflammation  will 
be  a  rubbing,  grating  sound  heard  over  or  shghtly  above  the  apex 
of  the  heart.  The  sound  has  a  double  quality  and  is  heard  both  at 
systole  and  diastole,  or  perhaps  only  with  systole.  The  sounds  are 
known  as  the  pericardial  friction  sounds.  In  well-marked  cases  they 
will  be  transmitted  to  the  finger  on  palpation.  Wherever  heard  they 
are  distinctly  localized.  The  right  cardiac  dulness  forms  an  obtuse 
angle  with  the  liver  dulness,  and  in  older  children  there  may  be  bulging 


376  THE    PRACTICE    OF    PEDIATRICS 

of  interspaces.  With  the  appearance  of  considerable  fluid  the  friction 
sounds  cease,  but  return  when  the  fluid  is  absorbed.  In  cases  in  which 
the  friction  is  questionable  or  indistinct,  it  wiU  be  accentuated  by- 
having  the  child  lean  forward  in  a  sitting  position. 

Percussion. — When  fluid  in  considerable  amount  is  present,  the  area 
of  cardiac  dulness  will  be  increased,  the  apex-beat  will  be  difficult  to 
determine,  and  the  normal  heart-sounds  will  become  weakened. 

In  a  fatal  case  in  a  six-year-old  boy  the  apex-beat  was  not  demonstrable,  find 
the  heart-sounds  could  scarcely  be  heard. 

It  has  not  been  my  observation  that  the  apex-beat  is  displaced  up- 
ward, as  is  claimed  is  the  case  in  adults.  With  the  presence  of  consider- 
able fluid, — over  two  ounces  in  a  child  from  three  to  five  years  of  age, — 
the  dulness  will  be  increased  to  the  left  and  upward. 

With  the  larger  effusion  occurring  in  the  boy  above  mentioned,  the  dulness 
extended  to  the  right  nipple  and  one  inch  outside  of  the  left  nipple. 

The  amount  of  fluid  is  difficult  to  determine  in  any  case,  and  particu- 
larly so  when  endocarditis  and  myocarditis  coexist,  with  accompany- 
ing hypertrophy  and  dilatation.  The  duration  of  the  acute  cases  of 
rheumatic  origin  varies  from  a  few  to  a  considerable  number  of  weeks. 

Prognosis. — The  prognosis  in  rheumatic  cases  is  good  if  proper 
treatment  can  be  followed.  I  have  lost  very  few  cases.  We  are  deal- 
ing with  a  disease  in  which  the  management  of  the  case  determines  to  a 
large  degree  the  outcome.  Just  how  complete  a  recovery  is  made  in 
the  so-called  recovery  cases  is  difficult  to  determine,  as  there  must  be, 
in  every  case,  adhesions  between  the  heart  and  the  pericardial  sac. 
A  condition  known  as  adherent  pericardium  (p.  393)  may  be  the  out- 
come. The  purulent  cases,  with  so-called  malignant  endocarditis, 
have  all  been  fatal,  so  far  as  my  own  observation  is  concerned. 

Treatment. — In  considering  the  treatment  we  may  divide  cases  of 
the  disease  into  two  groups — those  of  rheumatic  origin  and  those  due  to 
the  invasion  of  well-known  pathogenic  organisms.  In  the  rheumatic 
cases  the  sick-room  management  and  the  diet  are  the  same  as  in  the 
treatment  of  endocarditis  (p.  380).  In  addition  to  the  management 
pursued  in  endocarditis,  additional  symptomatic  treatment  is  required. 

For  controlling  excessive  rapidity  of  the  heart  the  tinctures  of 
strophanthus  and  aconite  may  be  of  much  service.  To  a  child  eight 
months  to  three  years  of  age  3^^  drop  of  tincture  aconite  and  one  drop 
of  tincture  strophanthus  may  be  given  at  two-hour  intervals,  but  not 
to  exceed  six  doses  in  the  twenty-four  hours.  After  the  third  year,  one 
drop  of  the  tincture  of  aconite  and  one  drop  of  the  tincture  of  strophan- 
thus may  be  given  at  two-hour  intervals — six  doses  in  the  twenty-four 
hours. 

For  the  extreme  restlessness  which  often  exists  codein  or  paregoric 
may  be  given.  For  a  child  under  two  years  of  age  paregoric  is  safer. 
It  may  be  given  in  doses  of  from  10  to  20  drops  and  repeated  when 
indicated  at  intervals  of  two  or  three  hours.     Older  children — between 


ACUTE    ENDOCARDITIS  377 

the  second  and  sixth  years — should  be  given  codein  in  doses  of  from 
Mo  to  j^^  grain.  After  the  sixth  year,  }-i  grain  may  be  given,  to  be 
repeated  at  three-hour  intervals  only,  not  more  than  three  doses  being 
given  in  twenty-four  hours. 

As  soon  as  the  diagnosis  is  made,  if  the  case  is  of  rheumatic  origin, 
it  is  advisable  to  begin  giving  the  salicylate  of  soda  (wintergreen),  with 
a  view  to  prevention  of  an  effusion  into  the  pericardial  sac.  To  those 
under  three  years,  14  to  20  grains  of  salicylate  of  soda  should  be 
given  daily  with  twice  the  amount  of  bicarbonate  of  soda.  As  the  sali- 
cylate may  cause  some  gastric  disturbance,  it  should  never  be  given 
when  the  stomach  is  empty,  except  in  milk  or  with  some  other  food;  4 
grains  is  as  much  as  should  be  given  at  one  time.  After  the  third  year, 
from  20  to  30  grains  of  the  salicylate  may  be  given.  At  the  tenth  year, 
40  grains  may  be  given  daily  in  divided  doses,  always  in  solution,  under 
the  same  precautions  as  to  giving  the  drug  after  meals.  It  is  impossible 
and  entirely  unnecessary  in  this  country  to  give  the  large  doses  of  the 
salicylate  which  are  given  abroad. 

For  delicate  children  and  those  by  whom  the  salicylate  is  not  well 
tolerated,  aspirin  may  be  substituted;  or  the  salicylate  may  be  given 
by  the  bowel,  in  doses  of  15  grains  at  a  time.  The  medicine  should  be 
diluted  with  at  least  4  ounces  of  water  and  introduced  through  a  rectal 
tube  which  has  been  inserted  at  least  9  inches.  It  should  not  be  given 
oftener  than  twice  daily,  and  should  be  immediately  preceded  by 
irrigation  of  the  large  intestine. 

In  the  comparatively  infrequent  cases  in  which  pericarditis  compli- 
cates one  of  the  infectious  diseases,  the  salicylate  treatment  is  not  to  be 
advised  unless  there  is  some  suspicion  of  rheumatism  in  the  case.  The 
other  methods  suggested  are  to  be  carried  out  with  the  hope  that  the 
disease  may  be  controlled.  In  this  type  of  case  the  ice-bag  is  particu- 
larly serviceable.  In  the  event  of  effusion  so  excessive  as  to  interfere 
with  the  heart  action,  producing  orthopnea  and  cyanosis,  with  feeble, 
irregular  pulse,  operation  on  the  pericardium,  such  as  aspiration  or 
incision  and  drainage,  is  to  be  considered,  although  in  the  few  operative 
cases  which  I  have  seen  I  have  not  been  impressed  with  the  great  useful 
ness  of  this  treatment.  On  the  other  hand,  I  have  seen  cases,  in  which 
there  was  an  excessive  accumulation  of  fluid,  recover  under  less  radical 
measures. 

The  Purulent  Type. — When  it  becomes  evident  that  pus  is  present 
in  the  sac,  incision  and  drainage  may  be  attempted,  as  the  case  will 
surely  be  fatal  if  the  usual  methods  are  pursued.  In  this  type  the 
blood  shows  a  very  high  white  cell  count  with  very  high  polynuclears. 

ACUTE  ENDOCARDITIS 

Acute  endocarditis  is  an  inflammation  of  the  endocardium,  or  lining 
membrane  of  the  heart.  Probably  in  all  cases  showing  even  a  moder- 
ate degree  of  severity  there  is  involvement  of  the  adjacent  heart  muscle, 
so  that  when  there  is  an  endocarditis,  there  is  a  myocarditis  as  well, 


378  THE    PRACTICE    OF    PEDIATRICS 

although  the  latter  may  be  of  httle  moment.  Pericarditis  has  been  a 
complication  in  about  5  per  cent,  of  my  cases.  In  the  great  majority 
of  instances  endocarditis  is  to  be  looked  upon  as  a  manifestation  of 
rheumatism  and  not  a  complication. 

Etiology. — Endocarditis  is  present  in  a  considerable  proportion  of 
cases  of  chorea,  the  statistics  of  various  authors  varying  from  6  to  55 
per  cent.  Both  the  chorea  and  the  endocarditis  are  active  manifesta- 
tions of  acute  rheumatism.  In  my  own  experience  endocarditis  has 
been  present  in  not  over  20  per  cent,  of  the  cases  of  chorea.  Endo- 
carditis occurs  as  a  complication  of  scarlet  fever,  diphtheria,  measles, 
and  tonsillitis.  In  fact,  there  are  few  diseases  of  bacterial  origin  with 
which  it  has  not  at  some  time  been  associated.  In  two  of  my  cases  it 
was  a  complication  of  grip. 

Age  of  Patients. — It  is  unusual  to  find  endocarditis  in  children 
under  three  years  of  age.  Few  cases  are  seen  between  the  third  and 
fifth  year.  The  period  of  greatest  susceptibility  is  between  the  fifth 
and  the  twelfth  years. 

Bacteriology. — The  vegetative  forms  of  endocarditis  are  more 
frequently  due  to  rheumatism  than  to  any  other  infectious  disease. 
Poynton  and  Payne  have  demonstrated  the  diplococcus  of  rheumatism 
in  the  vegetations  of  the  heart  valves.  The  bacteria  are  readily 
found  only  in  the  early  stage  of  the  endocarditis,  and  tend  to  disappear 
in  the  later  course  of  the  disease. 

Acute  ulcerative  or  septic  endocarditis  is  more  often  a  secondary 
than  a  primary  condition,  and  is  caused  by  the  localization  on  the  heart 
valves  of  bacteria  from  the  blood-stream.  The  bacteria  causing  the 
primary  infection  are  present  in  the  valvular  ulcers.  Streptococci, 
staphylococci,  pneumococci,  gonococci,  typhoid  bacilli,  colon  bacilli, 
influenza  bacilli,  and  diphtheria  bacilli  have  been  found. 

In  chronic  endocarditis  no  bacteria  are  demonstrable  in  the  endo- 
cardial lesions. 

Pathology. — Inflammation  of  the  membrane  lining  the  heart  affects 
chiefly  the  valves;  and  most  frequently,  those  guarding  the  mitral  and 
aortic  orifices.  The  latter  fact  has  been  explained  by  a  theory  that 
bacterial  development  is  better  favored  by  the  fresh  arterial  blood  of 
the  left  ventricle  than  by  the  venous  blood  (of  low  oxygen-content) 
present  in  the  right  heart. 

The  margins  of  the  affected  cusps  are  thickened  and  covered  with 
small  masses  of  necrotic  tissue,  fibrin,  red  corpuscles,  leukocytes,  pro- 
liferating endothelial  cells,  and  bacteria.  The  chordae  tendinese  are 
frequently  involved  and  undergo  shortening,  thickening,  and  a  certain 
amount  of  fusion.  In  mild  cases  the  integrity  of  the  segments  may  not 
be  lost,  but  more  frequently,  when  the  acute  inflammation  subsides, 
the  valves  undergo  considerable  cicatrization  and  contraction,  and 
exist  thenceforth  as  deformed  and  more  or  less  inefl&cient  structures. 

In  the  severe  forms  of  the  disease,  commonly  termed  malignant  en- 
docarditis, destructive  effects  are  much  more  marked,  and  ulceration  of 
the  mural  endocardium  may  occur.     In  such  cases  emboli  frequently 


ACUTE    ENDOCARDITIS  379 

become  detached  from  the  friable  vegetations  on  the  valves,  and  may 
produce  infarcts  and  abscesses  in  such  remote  organs  as  the  brain, 
spleen,  and  kidney. 

The  usual  sources  of  infection  are  wounds  of  the  skin  and  mucous 
membrane,  and  inflammation  of  the  alimentary,  pulmonary,  and  geni- 
to-urinary  tracts.  Prominent  in  this  category  undoubtedly  are  dis- 
eased tonsils.  Attacks  of  "  simple ''  acute  endocarditis  may  easily 
render  the  heart  more  susceptible  to  an  infection  of  the  malignant  type. 

Symptomatology. — By  far  the  majority  of  cases  of  endocarditis 
present  no  symptoms  whatever.  Hundreds  of  these  cases  are  over- 
looked because  of  this  peculiarity  of  the  disease,  and  because  writers  of 
medical  books,  in  describing  the  disease,  lay  great  stress  upon  a  symp- 
tomatology of  prostration,  high  temperature,  and  severity  in  general, 
that  may  occur  in  one  out  of  ten  cases,  the  result  being  that  nine  are 
overlooked.  A  large  majority  of  the  cases  of  endocarditis  coming 
under  my  observation  (mild  acute  endocarditis,  not  chronic  valvular 
disease)  have  been  discovered  in  the  routine  examination  of  the 
patient,  and  not  because  anything  in  the  case  had  suggested  the  heart 
as  a  factor  in  the  illness.  Every  physician  who  does  considerable 
cKnical  work  sees  patients  with  valvular  defects  of  long  standing,  who 
have  no  knowledge  whatever  that  a  heart  lesion  has  existed.  Those 
who  examine  for  life  insurance  will  particularly  appreciate  the  force  of 
the  above  statement.  Children  with  rheumatic  tendencies,  as  has  been 
mentioned,  are  very  susceptible  to  endocarditis.  I  have  repeatedly 
seen  cases  develop  after  or  with  a  tonsillitis  in  a  child  with  a  rheumatic 
tendency  or  inheritance,  the  endocarditis  being  the  active  manifesta- 
tion of  the  rheumatism. 

Illustrative  Case. — A  boy  six  years  of  age  had  a  slight  pain  in  his  knee,  which 
caused  a  limp.  He  had  just  recovered  from  a  mild  tonsillitis.  In  the  routine 
examination  an  acute  endocarditis  was  found,  involving  both  mitral  and  the 
Bortic  valves.     The  boy  made  a  complete  recovery. 

There  are  doubtless  many  cases  of  endocarditis  which  pass  unrecog- 
nized and  recover. 

When  symptoms  are  present,  we  find  fever  which  presents  wide 
variations, — 100°  to  105°F., — depending  upon  the  severity  of  the  in- 
fection. The  height  of  the  temperature  is  usually  a  reliable  indication 
of  the  gravity  of  the  illness.  With  the  high  temperature  there  will  be 
increased  heart  action — 110  to  140.  If  the  action  is  irregular,  myocar- 
ditis also  may  be  suspected.  Pain  over  the  precordium  and  shortness 
■of  breath  are  usually  present. 

Diagnosis. — The  symptoms  alone  may  be  sufficiently  pronounced 
to  suggest  the  existence  of  endocarditis.  It  is  by  the  physical  signs, 
however,  that  suspicion  is  verified  and  the  diagnosis  made  possible. 

Inspection. — Inspection,  if  it  reveals  anything  abnormal,  will  show 
an  excessive  action  of  the  heart,  producing  an  undulating  motion  of  the 
cardiac  area,  with  visible  apex-beat. 

Palpation. — Palpation  confirms  the  existence  of  this  overaction  of 
the  heart. 


380  THE    PRACTICE    OF   PEDIATRICS 

Percussion. — Percussion  may  reveal  cardiac  enlargement.  The  left 
ventricle  becomes  dilated  early  in  the  severe  cases. 

Auscultation. — Auscultation  will  reveal  either  a  murmur  (p.  369)  or 
a  combination  of  murmurs.  In  character  the  murmur  may  be  soft 
and  blowing,  or  harsh,  rough,  and  grating.  It  may  be  systolic, 
diastoUc,  or  presystolic;  or  it  may  be  double,  presystolic  and  systolic, 
or  diastolic  and  systohc.  The  fact  that  the  left  side  of  the  heart  is 
always  involved  simplifies  materially  the  localization  of  the  lesion. 

If  due  to  mitral  regurgitation,  the  murmur  is  usually  soft  and  blow- 
ing in  character,  heard  loudest  at  the  apex,  transmitted  upward  to  the 
axilla,  and  plainly  heard  between  the  scapula  and  the  spine. 

In  mitral  stenosis  the  murmur  is  presystolic  in  time,  and  is  heard 
loudest  just  above  the  site  of  the  apex-beat.  This  murmur  is  not 
transmitted  elsewhere,  and  is  accompanied  by  a  thrill  (p.  372) . 

When  there  is  combined  mitral  stenosis  and  regurgitation,  the  sys- 
tolic murmur  follows  immediately  upon  the  presystolic,  making  a  pro- 
longed murmur  which  completely  obUterates  the  first  heart-sound. 

Aortic  stenosis  produces  a  systolic  murmur,  heard  loudest  at  the 
second  interspace,  over  the  middle  of  the  sternum,  or  at  its  immediate 
right  border,  and  transmitted  upward  to  the  carotids. 

In  aortic  regurgitation  the  murmur  is  diastolic  in  time  and  is  heard 
loudest  over  the  second  and  third  interspaces. 

Differential  Diagnosis. — Endocarditis  may  be  confused  with  tem- 
porary functional  disturbances  of  the  heart,  giving  rise  to  functional 
murmurs  (p.  372).  This  statement,  of  course,  applies  only  to  mitral 
disease.  After  many  disorders  in  children  in  which  the  heart  has  been 
severely  taxed,  a  soft,  blowing,  systolic  murmur  develops.  This  mur- 
mur, however,  is  inconstant,  changes  more  or  less,  or  disappears  upon 
change  in  the  position  of  the  patient,  and,  most  important  of  all,  has 
no  line  of  transmission  and  is  not  heard  at  the  back.  After  a  few  days 
or  weeks,  providing  proper  management  is  carried  out,  such  murmurs 
disappear. 

Prognosis. — The  outlook,  in  a  great  majority  of  cases  of  endocardi- 
tis, is  favorable  for  a  complete  recovery.  In  other  cases,  even  under 
the  best  of  management,  the  patient,  after  recovering  from  the  acute 
disease,  is  left  with  crippled  valves.  When  there  is  a  very  severe  in- 
fection of  the  so-called  malignant  type,  the  outlook  is  most  unfavor- 
able. Recently  a  boy  seven  years  of  age  died  within  forty-eight  hours 
from  the  onset  of  the  heart  involvement.  1  have  seen  a  considerable 
number  of  similar  fatal  cases  in  consultation  work.  The  inflammation 
in  such  cases  usually  develops  rapidly  into  a  pancarditis,  the  heart 
muscle,  the  pericardium,  and  the  endocardium  all  becoming  rapidly  in- 
volved, with  resulting  dilatation  of  the  heart,  which  is  often  extreme. 

Treatment. — Rest  in  Bed. — Whatever  the  nature  of  the  infection, 
and  whether  the  disease  is  mild  or  severe,  one  rule — that  regarding 
quiet  and  rest — must  be  consistently  followed.  The  child  must  remain 
in  a  recumbent  position  in  bed,  the  bed-pan  being  used  to  receive  the 
discharges.     The  use  of  the  arms  and  the  hands  should  be  discouraged, 


ACUTE    ENDOCARDITIS  381 

particularly  early  in  the  attack,  as  it  is  at  this  time  that  the  greatest 
damage  is  done  to  the  heart.  Reaching  from  the  bed  to  the  floor  or  to 
the  table  or  chairs  should  be  forbidden.  The  heart  must  be  given  as 
little  work  to  do  as  possible. 

Prolonged  Inactivity. — In  both  pericarditis  and  endocarditis  absence 
of  stress  of  any  nature  should  be  secured  until  every  evidence  of  the 
disease  has  disappeared,  or  at  least  until  the  heart  becomes  regular,  and 
its  rate,  under  a  test  of  moderate  exercise,  approximates  the  normal. 
The  longest  period  I  have  kept  a  patient  recumbent  was  six  months. 
This  patient  is  now  a  young  man,  and  all  that  remains  of  his  very  ex- 
tensive endocarditis  and  pericarditis,  comprising  three  distinct  attacks, 
is  a  sUght  mitral  regurgitant  murmur  with  full  compensation.  Every 
patient  is  kept  off  the  feet  for  at  least  six  weeks,  and  several  have  not 
been  allowed  to  take  a  step  within  three  to  six  months. 

Diet. — The  diet  should  consist  largely  of  fluids,  administered  in 
comparatively  small  amounts,  at  shorter  intervals  than  in  health.  The 
bowels  should  move  once  daily.  If  a  laxative  is  necessary,  a  saline 
should  be  given.  A  Seidhtz  powder  or  magnesium  citrate  is  usually 
effective.  Distention  of  the  stomach,  whether  by  gas  or  by  food, 
causes  pressure  on  the  heart  and  increases  its  labor.  It  is  my  custom, 
in  these  cases,  to  give  five  feedings  in  twenty-four  hours,  and  not  more 
than  eight  ounces  at  a  feeding.  Four  ounces  of  milk  and  four  ounces 
of  gruel,  with  zwieback  or  toast,  constitute  the  usual  feeding.  In 
order  to  vary  the  diet,  a  weaker  gruel,  No.  1,  flavored  with  an  ounce  or 
two  of  chicken  or  mutton  broth,  may  be  given;  or  a  gruel  of  the  same 
strength  may  be  given  plain,  with  sufficient  salt  to  make  it  palatable. 
If  the  milk  is  well  borne,  it  may  be  increased  until  one  quart  is  taken 
daily.  The  enforcement  of  a  strict  milk  diet  is  a  mistake.  The  child 
very  soon  tires  of  it,  digestion  is  impaired,  and  nutrition  is  correspond- 
ingly faulty.  As  the  case  improves,  eggs,  bread  and  butter,  stewed 
fruit,  poultry,  fish,  and  plain  puddings  may  be  added  to  the  diet.  In 
order  to  facilitate  freer  feeding  the  number  of  meals  should  be  reduced. 

The  Ice-hag. — A  screw-top  ice-bag  half  filled  with  chopped  ice 
should  be  placed  over  the  heart,  and,  if  possible,  kept  on  continuously. 
Children  frequently  become  restless  and  irritable  under  too  constant 
application  of  the  ice,  and  in  such  instances  it  may  be  left  off  occa- 
sionally for  half  an  hour  or  an  hour. 

Drugs. — In  endocarditis  following  diphtheria  or  the  exanthemata 
drugs  are  of  little  benefit.  Salicylate  of  soda  seems  to  have  no  bene- 
ficial effect  upon  these  patients.  For  excessive  rapidity  of  the  heart 
action  the  tincture  of  strophanthus  is  more  effective  than  any  other 
drug.  To  children  from  five  to  ten  years  of  age  two  drops  may  be  given 
at  intervals  of  from  three  to  six  hours.  If  there  is  much  excitability 
and  restlessness,  }-i  grain  of  codein  or  8  grains  of  sodium  bromid  may 
be  given  at  sufficiently  frequent  intervals  to  control  the  condition. 
WHiile  every  case  of  non-rheumatic  endocarditis  presents  possibilities 
of  serious  and  permanent  damage  to  the  heart,  not  every  case,  by  any 
means,  is  of  sufficient  severity  to  demand  other  treatment  than  the  ice- 


382  THE  PRACTICE  OF  PEDIATRICS 

bag,  rest,  and  an  easily  digested  diet.  It  is  often  the  milder  cases  that 
occasion  the  gravest  sequelae,  on  account  of  the  lack  of  objective  symp- 
toms, and  the  liberties  given  the  child  by  parents,  who  are  with 
difficulty  convinced  of  the  gravity  of  the  disease. 

Antirheumatic  Treatment. — Every  case  of  endocarditis  under  my 
care  which  is  not  directly  associated  with  one  of  the  infectious  diseases 
is  considered  and  treated  as  though  it  were  a  case  of  rheumatism,  owing 
to  the  exceeding  frequency  of  this  form  of  infection.  Sodium  sali- 
cylate, and  sodium  bicarbonate  are  early  brought  into  use.  To  a  child 
between  five  and  ten  years  of  age,  from  3  to  5  grains  of  sodium  sali- 
cj'late  obtained  from  wintergreen,  with  an  equal  quantity  of  sodium 
bicarbonate,  are  given  after  each  feeding,  five  times  daily.  The  medi- 
cine may  be  given  in  capsules  or  in  solution.  If  the  sodium  salicylate 
is  not  well  borne  by  the  stomach,  the  equivalent  dosage  of  aspirin  or 
oil  of  wintergreen  may  be  given.  The  salicylate  should  be  continued 
with  occasional  intermissions  of  a  day  or  two  until  such  urgent  symp- 
toms as  fever,  rapid  heart-rate,  and  dyspnea  have  subsided.  The 
dosage  should  then  be  varied,  10  grains  being  given  daily  for  five  days 
out  of  fifteen.  A  child  who  has  recovered  from  rheumatic  endocarditis 
should  be  kept  under  close  observation,  and  the  parents  should  be 
warned  as  to  the  possibilities  of  a  second  attack. 

Illustrative  Cases. — In  a  private  case,  in  spite  of  antirheumatic  treatment, 
during  the  intervals  four  distinct  attacks  have  occurred  during  the  past  five 
years. 

A  dispensary  patient  at  the  New  York  Polyclinic  had  his  first  attack  when  four 
years  of  age.  So  prominent  was  his  rheumatic  tendency  that  during  the  next  four 
years,  in  spite  of  active  antirheumatic  treatment  and  a  careful  diet  in  the  intervals, 
he  had  eight  distinct  attacks  of  endocarditis  and  died  from  the  heart  involvement 
in  his  eighth  year.  There  were  other  manifestations  of  rheumatism  in  his  case, 
and  his  family  on  both  sides  for  several  generations  had  been  markedly  rheumatic. 

Recurrence. — Inasmuch  as  a  recurrence  is  very  probable,  the  patient, 
even  while  in  apparent  health,  should  have  the  benefit  of  a  restricted 
diet,  being  allowed  red  meat  but  twice  a  week  and  a  minimum  amount 
of  cane-sugar.  During  five  days  out  of  each  month  he  should  receive 
10  grains  of  sodium  sahcylate  (wintergreen)  and  10  grains  of  sodium 
bicarbonate  daily.  This  scheme  of  medication  should  be  continued 
for  at  least  two  years,  and  much  longer  if  the  patient  shows  any  further 
rheumatic  manifestation,  such  as  pains  in  the  legs  or  repeated  attacks 
of  tonsilhtis.  The  length  of  time  during  which  absolute  rest  in  bed  is  to 
be  enjoined  depends  on  the  severity  of  the  case.  This  time,  in  my 
primary  cases,  is  from  six  weeks  to  three  months.  In  the  case  of  a  boy 
who  had  had  a  very  severe  second  attack,  walking  was  not  allowed  for 
six  months,  the  patient  using  a  wheel-chair  instead. 

The  rapidity  of  the  heart's  action  is  the  best  guide  in  deciding  when 
the  patient  shall  be  allowed  to  walk.  In  a  case  of  moderate  severity 
the  heart's  action,  which  has  been  rapid, — 140  to  160, — gradually  be- 
comes less  frequent.  The  temperature  may  have  continued  for  only  a 
week  or  ten  days. 


MYOCARDITIS  383 

Every  child  who  has  had  acute  endocarditis  should  have  the  tonsils 
enucleated. 

Convalescence. — When  the  pulse-beat  is  reduced  to  100,  which  is 

not  to  be  expected  earher  than  the  fourth  week,  the  patient  may  be 

allowed  to  sit  in  a  rechning  chair.     Previous  to  this,  while  still  in  bed, 

he  may  be  gradually  accustomed  to  elevation  of  the  head  by  the  addi- 

ition  of  an  extra  pillow  for  an  hour  or  more  daily.     Greater  freedom 

,  is  permitted  when  it  is  found  that  the  patient  can  be  indulged  and  the 

■heart-rate  still  be  kept  below  100. 

The  above  scheme  of  management  may  seem  unnecessarily  severe, 
but  we  must  remember  the  importance  of  the  heart  in  the  economy, 
and  see  to  it  that  if  the  patient  cannot  have  a  perfectly  sound  heart,  it 
shall  be  damaged  as  little  as  possible.  The  treatment  thus  comprises 
the  observance  of  every  precaution  that  will  tend  toward  the  best 
possible  outcome,  no  matter  how  drastic  may  be  the  requirements. 

MYOCARDiriS 

Myocarditis  of  mild  degree  is  a  frequent  accompaniment  of  inflam- 
matory disease  of  the  pericardium  and  endocardium.  The  most  severe 
cases,  however,  may  not  be  of  this  type. 

Etiology. — Acute  parenchymatous  myocarditis  may  follow  various 
processes,  but  is  most  often  due  to  the  activity  of  the  toxin  of  the  pneu- 
mococcus,  the  typhoid  bacillus,  or  the  diphtheria  bacillus.  Inflam- 
mation of  the  endocardium  or  the  pericardium  may  extend  to  the 
myocardium.. 

Further  references  to  the  causation  of  this  disease  are  included  in 
the  discussion  of  the  pathology. 

Pathology. — Classifications  of  myocarditis  are  more  or  less  artificial. 
Acute  and  chronic  forms  and  parenchymatous  and  interstitial  types  of 
inflammation  are  recognized. 

Acute  parenchymatous  myocarditis  usually  results  from  an  acute 
infection  or  toxemia,  such  as  diphtheria,  typhoid,  or  scarlet  fever.  The 
heart  muscle  is  pale  in  color,  soft,  and  somewhat  friable.  The  heart 
itself  may  be  dilated.  Microscopically,  the  muscle-cells  show  granular, 
hyaline,  and  fatty  degenerative  changes,  and  frequently  contain 
vacuoles;  the  nuclei  stain  imperfectly.  In  the  interstitial  tissue,  poly- 
nuclear  and  lymphocytic  infiltration  and  even  some  extravasation  of 
blood  may  occur,  these  conditions  being  most  marked  in  the  neighbor- 
hood of  blood-vessels. 

The  reparative  process  is  largely  that  of  replacement  fibrosis,  a 
productive  inflammation  terminating  in  the  substitution  of  fibrous 
connective  tissue  for  the  degenerated  cells.  Development  of  new 
muscle  tissue  also  occurs.  This,  however,  is  probably  brought  about 
by  simple  hypertrophy  of  undegenerated  muscle-fibers,  rather  than  by 
true  hyperplasia  of  these  elements. 

Acute  suppurative  myocarditis  may  result  directly  from  an  abscess 
in  the  mediastinum  or  a  purulent  pericarditis,  but  is  more  frequently 


384  THE    PRACTICE    OF    PEDIATRICS 

due  to  a  general  pyemia  caused  by  the  pneumococcus,  streptococcus, 
staphylococcus,  or  gonococcus.  The  wall  of  the  heart  contains  miliary 
pus  foci  and  small  extravasations  of  blood.  Microscopic  examination 
shows  the  vessels  to  be  filled  with  embolic  products,  and  surrounded 
by  the  small  hemorrhagic  areas  and  collections  of  pus-cells  already 
described.  The  process,  although  essentially  one  of  interstitial  in- 
flammation, is  regularly  accompanied  by  considerable  degeneration  of 
the  muscle-fibers'.  In  the  rare  cases  where  recovery  from  suppurative 
myocarditis  occurs,  the  defects  in  the  heart  are  remedied  by  fibrous 
tissue. 

Chronic  interstitial  myocarditis  in  childhood  is  a  productive  repara- 
tive process,  usually  secondary  to  inflammation  of  the  acute  type. 
The  development  of  this  condition  to  compensate  for  atrophy  of  the 
heart  musculature  caused  by  defective  blood-supply  through  partially 
occluded  coronary  arteries  is  essentially  a  change  of  later  life.  When 
due  to  syphilis,  chronic  myocarditis  in  children  is  usually  accompanied 
by  endarteritis.  Gummata  are  rare,  although  Treponema  pallidum 
may  be  demonstrated  in  the  myocardium. 

Symptoms. — The  most  characteristic  early  sign  of  myocarditis 
in  a  child  is  a  persistently  irregular  pulse,  with  or  without  a  tendency 
to  increased  rapidity.  It  is  not  at  all  essential  that  the  pulse  be  rapid 
— in  fact,  it  is  not  at  all  unusual  for  it  to  be  slower  than  normal.  When 
such  irregularity  occurs  after  an  acute  disease,  and  particularly  when 
there  are  occasional  periods  of  cyanosis,  myocarditis  may  be  expected. 
It  is  often  difficult  to  judge  accurately  of  the  heart's  action  when  the 
child  is  awake,  because  of  the  excitement  and  possible  resistance  which 
the  presence  of  the  physician  may  occasion.  For  this  reason,  in  sus- 
pected cases,  the  child  should  be  examined,  if  possible,  when  asleep. 

When  the  child  develops  the  above  symptoms,  he  should  be  watched 
with  the  greatest  solicitude,  as  the  more  urgent  symptoms  of  pallor, 
marked  cyanosis,  and  syncope  may  occur  at  any  moment.  The  pulse 
becomes  very  irregular  and  thready,  or  it  may  be  lost  entirely  at  the 
wrist,  the  patient  presenting  a  picture  of  impending  dissolution.  In 
pneumonia,  in  septic  cases  of  diphtheria,  and  in  the  exanthemata,  the 
symptoms  of  acute  myocarditis  are  those  of  early  heart  failure  and 
are  of  grave  significance.  The  pulse  becomes  rapid  and  irregular, 
cyanosis  is  constant,  and  the  respiration  is  increasingly  difficult  be- 
cause of  the  sense  of  pressure  and  constriction  in  the  cardiac  region. 

Diagnosis. — The  diagnosis  is  based  upon  the  irregularity  of  the 
pulse  following  an  acute  infectious  disease,  and  upon  the  sudden  at- 
tacks of  cyanosis  and  collapse.  Auscultation  is  of  value  only  in  dem- 
onstrating the  weakness  and  indefiniteness  of  the  first  sound. 

Treatment. — Rest  in  Bed. — When  the  condition  of  myocarditis 
follows  even  a  mild  attack  of  one  of  the  infectious  diseases,  the  invari- 
able rule  of  absolute  heart  rest,  which  I  consider  the  most  important 
feature  in  the  treatment,  must  be  insisted  upon.  The  patient,  whether 
in  hospital  or  in  private  practice,  should  not  be  allowed  to  sit  up  or  even 
to  raise  his  head  from  the  pillow;  a  trained  nurse  should  remain  con- 


MYOCAEDITIS  385 

stantly  in  attendance,  so  that  the  child  may  be  read  to,  or  otherwise  en- 
tertained while  physical  exertion  is  prevented.  He  may  be  permitted 
to  use  his  arms,  to  play  with  simple  Ught  toys,  but  all  other  exertion 
must  be  prohibited.  Aside  from  provisions  for  the  recumbent  position, 
quiet,  a  daily  bowel  evacuation,  and  easily  digested  food,  given  in 
small  quantities,  little  treatment  is  required.  It  is  important  to  keep 
the  stomach  free  from  distention  with  either  gas  or  food.  I  prefer  small 
quantities  of  nourishment  administered  at  frequent  intervals  to  large 
quantities  of  food  given  at  the  usual  meal- time. 

Drugs. — In  the  more  severe  cases  with  cyanosis  and  dyspnea  a 
hypodermic  loaded  with  strychnin,  y-io  grain,  and  digitalin.  Moo  grain, 
should  be  kept  constantly  at  the  bedside. 

In  one  of  my  cases  following  scarlet  fever  so  urgent  were  the  symptoms  that 
three  physicians  were  engaged  for  several  days,  each  being  for  eight  hours  daily  at 
the  bedside,  in  addition  to  the  two  trained  nurses,  each  of  whom  was  doing  twelve 
hours'  duty. 

My  patients  have  all  been  given  strychnin,  with  the  thought  of 
possible  associated  involvement  of  the  cardiac  ganglion.  Moreover, 
certain  portions  of  the  heart  muscle  obviously  remain  free  from  the  de- 
generative process  and  may  be  favorably  influenced  by  the  strychnin. 
To  a  child  one  year  of  age  /-^oo  grain  may  be  given  three  times  daily. 
From  the  first  to  the  third  year,  Moo  to  Moo  grain  may  be  given  four 
times  daily.  After  the  third  year  the  dose  is  subject  to  considerable 
variation,  the  amount  depending  upon  the  urgency  of  the  case.  Ordi- 
narily, from  Moo  to  Ms  grain  may  be  given  four  times  a  day.  If  the 
case  is  very  urgent  and  the  strychnin  appears  to  improve  the  heart 
action,  it  may  be  given  to  the  point  of  producing  its  physiologic  effects, 
such  as  fibrillary  twitching  of  the  muscles  of  the  face  and  the  backs  of 
the  hands.  Nitroglycerin  should  not  be  used.  Digitalis  should  be 
given  but  rarely  to  young  children,  as  it  is  very  apt  to  disturb  the  di- 
gestion if  long  continued;  temporarily,  in  treating  older  children,  it 
may  be  used  with  advantage.  A  child  from  five  to  ten  years  of  age  may 
be  given  daily  (and  preferably  after  meals)  from  three  to  four  drops  of 
the  tincture  well  diluted  with  water.  The  tincture  of  strophanthus 
may  be  of  more  service  than  any  other  drug.  It  will  be  found  particu- 
larly useful  in  those  cases  in  which  there  is  a  tendency  to  rapidity  of  the 
heart  action.  A  child  one  year  of  age  may  be  given  one  drop  every  two 
hours  in  the  twenty-four;  from  the  first  to  the  third  year,  from  one  to 
two  drops  at  two-hour  intervals;  and  from  the  third  to  the  tenth  year, 
from  two  to  four  drops  at  intervals  of  from  two  to  three  hours. 

Convalescence. — The  tendency  of  myocarditis  in  children  is  toward 
recovery.  How  long  each  patient  will  require  strict  observation,  and 
how  long  the  treatment  will  ultimately  need  to  be  continued,  must  be 
determined  by  each  individual  case.  One  fact  to  be  remembered, 
according  to  my  cases,  is  that  the  child  either  dies  suddenly  or  makes  a 
complete  recovery,  so  that  in  treatment  it  is  well  to  err  on  the  side  of 
caution.  I  have  found  it  safe,  in  a  very  few  instances,  to  allow  the 
child  to  sit  up  after  six  weeks. 
25 


386  THE    PRACTICE    OF    PEDIATRICS 

In  the  very  severe  case  above  referred  to  it  was  not  safe  for  the  patient  to  sit  up 
in  bed  until  the  end  of  the  third  month,  and  he  was  not  allowed  to  walk  until  the 
end  of  the  fourth  month.  After  being  kept  under  observation  for  one  year  he  was 
discharged,  and  has  remained  well  during  the  ten  years  \yhich  have  since  elapsed. 
At  the  present  time  there  is  no  evidence  whatever  of  his  former  illness. 

A  safe  rule  to  follow  is  to  keep  the  patient  in  bed  as  long  as  the  ra- 
pidity or  irregularity  of  the  heart  exists.  When  the  heart  action  in  the 
recumbent  position  is  apparently  normal,  the  patient  may  be  allowed 
to  have  his  head  raised  by  an  additional  pillow.  In  this  way  the  head 
and  shoulders  may  be  gradually  raised  higher  day  by  day,  so  long  as  the 
effect  upon  the  heart  muscle  is  not  unfavorable.  In  the  same  way, 
standing  and  walking  may  be  gradually  begun.  Following  out  this 
careful  method  of  heart  rest,  and  being  governed  solely  by  the  heart 
action,  which  indicates  the  heart  power,  I  have  seen  apparently  hopeless 
cases  completely  recover.  Whether  fibrous  changes  are  present  which 
may  have  a  later  influence  there  is,  of  course,  no  means  of  knowing. 

CONGENITAL  HEART  DISEASE 

In  congenital  heart  disease  there  is  a  structural  fault.  The  heart 
in  one  or  more  respects  is  anatomically  imperfect. 

Symptomatology. — Congenital  heart  disease  is  sometimes  suggested 
by  the  appearance  of  the  patient.  There  may  be  cyanosis,  which  is 
observed  only  when  the  child  cries  or  strains,  or  the  patient  may  be  a 
"blue  baby,"  in  which  case  the  cyanosis  is  permanent  and  of  such  a 
degree  as  to  make  the  diagnosis  positive  without  further  aid  than 
inspection. 

By  far  the  greater  number  of  my  cases  have  been  discovered  in  the 
routine  examination  and  had  presented  no  external  sign  whatsoever 
that  a  lesion  existed. 

Prognosis. — The  future  of  the  child  with  the  congenitally  defective 
heart  is  very  uncertain.  I  have  seen  a  very  few  of  these  patients  go  on 
to  the  adult  period  of  life  and  suffer  no  inconvenience.  In  by  far  the 
larger  number,  however,  the  approach  of  the  runabout  and  active 
period  (if  the  child  survives  to  this  time) ,  with  the  extra  demand  upon 
the  organ  that  this  age  necessitates,  results  in  failure  of  compensation 
and  dilatation,  followed  by  the  usual  train  of  symptoms  peculiar  to 
right  heart  failure. 

A  girl  with  congenital  heart  disease  developed  several  attacks  of  angina  and 
cyanosis  at  the  thirtieth  month.  This  continued  at  rather  infrequent  intervals 
for  a  year,  when  she  died  in  an  attack. 

Pathology. — The  initial  and  chief  lesion  in  the  majority  of  cases  is 
at  the  pulmonary  orifice,  and  is  supposedly  due  to  a  fetal  endocarditis 
which  causes  a  stenosis  at  this  orifice,  which  in  time,  through  interfer- 
ence with  the  blood-current,  prevents  a  closure  of  the  auricular  or 
ventricular  septum. 

Cases  are  occasionally  seen,  however,  in  which  the  defect  in  one  or 
other  of  the  septa  exists  without  atresia  or  stenosis  at  the  pulmonary 
orifice. 


CONGENITAL    HEART   DISEASE 


387 


Patent  ductus  arteriosus  is  rare.  Its  presence  is  usually  associated 
with  other  defects,  such  as  pulmonary  obstruction  and  septum  defects. 

Changes  in  the  great  vessels  are  occasionally  encountered.  Thus, 
the  aorta  may  have  its  origin  from  the  right  ventricle,  and  the  pul- 
monary artery  from  the  left  ventricle. 

Cardiac  Enlargement. — Enlargement  of  the  heart  is  the  rule  in 
congenital  cases.  Usually  the  right  heart  will  be  found  particularly 
involved. 

The  above  conditions  represent  some  of  the  more  common  abnor- 
malities. One  who  has  observed  many  autopsies  upon  children  has  had 
abundant  opportunity  to  verify  the  above  statements  and  to  see  other 
abnormalities  which  are  of  academic  interest  only. 


Fig.  47. — Clubbed  fingers  in  congenital  heart  disease. 


Classification  of  Lesions. — It  is  a  hopeless  task  to  attempt  to 
classify  a  congenital  lesion  according  to  the  nature,  maximum  intensity, 
or  transmission  of  the  murmur.  I  have  seen  this  attempted  time  and 
again,  the  autopsy  showing  results  that  were  not  flattering  to  the 
diagnostic  acumen  of  the  examiner. 

Diagnosis  in  Infants  and  Very  Young  Children. — The  most  sugges- 
tive feature  relating  to  diagnosis  is  a  pronounced  cardiac  murmur  in  a 
child  under  eighteen  months  of  age.  Children  before  this  period  of  life 
rarely  have  rheumatism,  which  is  the  cause  of  endocardial  lesions  in 
over  95  per  cent,  of  the  cases.  The  absence  of  cyanosis  is  no  evidence 
against  the  diagnosis  of  a  congenital  lesion,  as  a  great  majority  of  my 
cases  have  not  shown  this  symptom.  On  the  other  hand,  there  may  be 
a  marked  degree  of  cyanosis  and  not  the  slightest  trace  of  a  murmur. 
At  autopsy  such  a  case  showed  an  entire  absence  of  the  ventricular 
septum. 


388  THE    PRACTICE    OF    PEDIATRICS 

First,  then,  the  age  of  the  child  is  strongly  suggestive  as  to  whether 
the  condition  is  due  to  a  congenital  abnormality  or  an  acquired  disease. 
If  the  patient  is  under  eighteen  months  of  age  or  even  under  two  years, 
the  lesion  is  in  all  probabihty  congenital. 

Second  in  importance  I  would  place  the  character  of  the  murmur, 
which  is  usually  systolic  and  of  a  very  loud,  rasping  character,  heard 
loudest  in  the  third  or  fourth  left  intercostal  space  with  a  very  wide 
area  of  diffusion.  Many  of  these  murmurs  may  be  heard  over  the 
entire  thorax,  both  anteriorly  and  posteriorly. 

Differential  Diagnosis  in  Infants. — At  this  period  of  life  the  murmur 
of  congenital  heart  disease  has  to  be  differentiated  from  the  murmur 
found  in  anemia.  Not  all  congenital  murmurs  are  as  characteristic 
as  above  described.  They  may  lack  the  element  of  loudness  and 
harshness  and  be  soft  and  blowing  in  character.  This,  however,  is  of 
very  infrequent  occurrence.  In  such  an  event  a  differential  diagnosis 
between  a  congenital  cardiac  lesion  and  a  murmur  due  to  anemia  is 
most  difficult,  for  the  anemic  murmur  is  systolic  in  time,  is  heard  loud- 
est over  the  base,  and  has  a  fairly  evenly  distributed  area  of  diffusion  in 
all  directions. 

In  such  cases  the  blood  examination  is  of  decided  service.  In  con- 
genital heart  disease  there  is  almost  constantly  a  very  extreme  poly- 
cythemia with  high  hemoglobin  percentage  and  specific  gravity,  and  a 
moderate  increase  in  the  white  cells  (Wood). 

Murmurs  Constant — This  fact  is  a  valuable  aid  in  differentiation. 
Murmurs  due  to  a  lesion  are  constant  and  vary  little  under  different 
states.  Whether  the  patient  is  at  exercise,  at  rest,  sitting,  standing,  or 
lying  down,  the  murmurs  are  invariably  present  and  vary  only  in 
intensity. 

The  Functional  Murmur. — The  chief  characteristic  of  the  functional 
murmur  is  the  inconstancy  of  the  sound,  now  loud,  now  weak.  Not  in- 
frequently these  murmurs  disappear  under  stress  and  reappear  when 
the  stress  is  removed.  They  may  disappear  or  become  very  faint  with 
the  patient  recumbent,  and  reappear  upon  the  return  to  the  erect  po- 
sition.    A  relaxed  heart  muscle  might  be  a  cause  of  some  of  these  cases. 

The  anemic  murmur  changes  upon  change  in  position  of  the  patient, 
and  during  exercise  it  is  inconstant. 

Diagnosis  and  Differential  Diagnosis  in  Older  Children. — In  chil- 
dren after  the  second  year  the  differential  diagnosis  may  also  be  difficult. 
It  is  to  be  remembered  that  in  cases  in  which  a  congenital  murmur  is 
well  marked  at  this  period  of  life  there  will  usually  be  other  signs  that 
may  aid  us  in  our  judgment.  Cyanosis  is  present  in  a  larger  proportion 
of  the  older  patients  than  of  the  very  young.  This  is  to  be  explained  by 
the  fact  that  the  child,  when  very  young,  calls  upon  the  heart  to  a 
comparatively  small  extent.  With  the  assumption  of  active  play  and 
with  running,  stair-climbing,  and  stress  of  any  nature,  the  defective 
heart  fails  to  meet  the  extra  demands,  and  cyanosis,  clubbed  fingers 
(Fig.  47),  and  shortness  of  breath  develop.  At  this  age,  also  the  ques- 
tion of  anemia  and  developmental  conditions  arises.     I  have  repeatedly 


CHRONIC   VALVULAR    DISEASE    OF   THE    HEART  389 

seen  patients  who  showed  no  inconvenience  whatever  until  this  more 
active  period  of  life  was  reached. 

Murmur  After  Illness. — The  murmur  of  congenital  disease  is  also 
to  be  differentiated  from  other  functional  murmurs  than  those  of 
anemia  (p.  403),  which  are  practically  all  systohc  in  time  and  have  a 
wide  area  of  diffusion.  These  functional  murmurs  often  occur  during, 
or  particularly  after,  severe  illnesses,  such  as  pneumonia  or  typhoid 
fever,  when  the  heart  has  been  severely  taxed.  With  such  a  murmur 
there  is  no  accentuation  of  the  second  sound,  no  accompanying  dropsy 
or  cardiac  enlargment,  and  the  murmur  is  inconstant  and  variable 
being  influenced  by  the  activity  of  the  heart  and  the  position  of  the 
patient. 

CHRONIC  VALVULAR  DISEASE  OF  THE  HEART 

Chronic  valvular  disease  of  the  heart  (acquired)  is  the  end-result  of 
an  endocarditis  which  has  resulted  in  certain  changes  in  the  valves  and 
cardiac  orifices,  producing  a  permanent  lesion.  The  acquired  lesion  in 
children  will  practically  always  be  found  on  the  left  side  of  the  heart, 
involving  the  mitral  and  aortic  valves.  With  such  lesions,  compensa- 
tory hypertrophy,  a  conservative  process,  is  usually  associated. 

Etiology. — A  most  important  feature  to  keep  in  mind  in  connection 
with  valvular  disease  of  the  heart  in  children  is  the  source  of  the  dis- 
ease. A  large  proportion  of  the  cases  (95  per  cent,  in  my  own  experience) 
are  due  to  rheumatic  endocarditis.  In  the  absence,  then,  of  a  history 
of  endocarditis  in  association  with  pneumonia,  diphtheria,  or  scarlet 
fever,  which  in  my  experience  has  been  of  rare  occurrence,  it  may  be 
assumed  that  the  valvular  lesion  is  of  rheumatic  origin,  even  though 
there  may  not  be  elsewhere,  at  the  time,  positive  evidence  of  rheuma- 
tism. Not  a  few  children  showing  cardiac  disease  without  a  history  of 
actual  acute  rheumatism  have  a  history  of  tonsillitis,  angina,  coryza, 
asthmatic  bronchitis,  or  chorea,  all  showing  recurrent  tendencies. 
Such  patients  will  often  be  found  to  have  a  rheumatic  or  gouty  ances- 
try, and  not  infrequently  they  themselves  are  hearty  eaters  of  red  meat 
and  sugars. 

The  great  majority  of  cases  of  valvular  defects  recognized  in  early 
adult  life  are  the  result  of  unrecognized  endocarditis  of  childhood. 

Janeway*  finds  that  proved  bacterial  endocarditis  is  one  of  the  rare 
causes  of  chronic  valvular  disease. 

Symptomatology. — Chronic  valvular  disease  in  children  may  exist 
unchanged  for  years  if  the  lesion  is  not  severe  and  if  compensation  is 
maintained. 

The  first  symptoms  of  failure  of  compensation  are  shortness  of 
breath  and  rapidity  of  heart  action,  both  of  which  the  child  will  mention 
in  describing  the  condition.  If  the  heart  is  not  relieved,  the  patient 
will  soon  present  evidence  of  right  heart  involvement,  such  as  persist- 
ent general  bronchitis,  inability  to  assume  the  recumbent  position, 
dropsy,  and  enlargement  of  the  liver  and  spleen.  Later  the  breathing 
*  Boston  Med.  and  Surgical  Journal,  vol.  clxxiv,  No.  xxvi. 


390  THE    PRACTICE    OF    PEDIATRICS 

becomes  more  difficult,  the  expression  anxious,  and  the  face  drawn  and 
cyanosed  upon  the  sHghtest  exertion.  The  superficial  veins  become 
dilated,  and  the  pulse  finally  becomes  very  irregular  and  soft.  Death 
in  children  with  this  disease  is  usually  due  to  terminal  broncho- 
pneumonia. 

Diagnosis. — Valvular  lesions  are  indicated  by  adventitious  heart- 
sounds,  known  as  murmurs  (p.  370),  which  are  heard  either  with,  or 
in  place  of,  the  normal  sounds  (p.  368). 

The  character,  time,  point  of  maximum  intensity,  and  area  of  trans- 
mission indicate  the  location,  and  to  a  fairly  accurate  degree  the 
nature,  of  the  lesion. 

Prognosis. — The  prognosis  depends  to  a  large  degree  upon  both  the 
location  and  the  nature  of  the  lesion.  In  mitral  regurgitation  with 
good  compensation  the  possibilities  for  long  life  are  favorable,  depend- 
ing somewhat,  of  course,  upon  the  age  and  condition  of  the  patient. 
If  the  case  is  of  long  standing,  the  possibility  of  a  complete  cure  is  not  to 
be  considered.  An  unknown  factor  in  these  cases  which  has  important 
bearing  upon  the  future  is  the  possibility  of  reinfection.  When  rheu- 
matic endocarditis  has  once  existed  in  a  child  it  is  liable  to  return ;  and 
in  the  event  of  recovery  from  a  second  or  third  attack,  the  heart  is  left 
in  a  more  serious  condition  than  ever  before. 

Mitral  regurgitation  with  good  compensation  may  not  seriously  in- 
convenience the  individual  for  years  if  careful  habits  of  life  are  fol- 
lowed. Neither  need  a  mild  degree  of  uncomplicated  aortic  stenosis 
cause  great  anxiety.  Nevertheless,  I  always  look  upon  stenosis  at 
either  the  mitral  or  aortic  orifice  with  apprehension,  and  my  own  re- 
sults with  the  stenosis  cases  during  years  of  observation  have  been  far 
from  satisfactory.  Aortic  regurgitation  is  often  associated  with 
aortic  stenosis,  and  the  outlook  for  such  patients  as  well  as  those  with 
mitral  stenosis  is  not  favorable  as  regards  the  duties  of  active  adult  hfe. 

If  there  is  one  word  more  than  another  that  typifies  the  life  of  a 
child,  it  is  the  word  "stress."  Activity  and  excitement  are  so  in- 
herently a  part  of  child  life  that  the  heart  crippled  by  aortic  dis- 
ease is  often  called  upon  to  do  work  which  is  impossible.  Even  if 
the  patient  attains  the  fifteenth  year  without  loss  of  compensation, 
the  heart  is' in  a  condition  that  entails  semi-invaHdism. 

Treatment. — Realizing  that  rheumatic  endocarditis  is  very  likely 
to  return,  we  should  make  it  our  first  duty,  after  acquainting  ourselves 
with  the  probable  origin  of  a  given  case  of  valvular  disease,  to  explain 
to  the  parents  that  other  attacks  are  liable  to  occur  unless  means  are 
used  for  their  prevention.  Enucleation  of  the  tonsils  should  be 
practised  here  as  after  acute  endocarditis. 

In  the  absence  of  a  history  of  endocarditis  in  association  with  pneu- 
monia, diphtheria,  scarlet  fever,  or  other  infections,  it  may  be  assumed 
that  the  lesion  is  of  rheumatic  origin,  even  though  a  history  or  actual 
evidences  of  rheumatism  may  be  lacking. 

Our  first  step  in  the  management  must  be  to  regulate  the  life  so  as 
to  prevent  a  recurrence  of  the  heart  involvement.     With  this  end  in 


CHRONIC   VALVULAR    DISEASE    OF    THE    HEART  391 

view,  it  shoud  be  directed  that  red  meat  be  given  the  child  but  once 
every  second  day,  and  that  cane-sugar  be  given  in  great  moderation. 

A  diet  of  plain,  nutritious  food,  with  nothing  between  meals,  is  a 
very  important  feature  in  the  treatment  of  heart  disease  in  children. 
Poultry,  fish,  eggs,  milk,  and  high-proteid  cereals  may  be  given  in  in- 
creased amount  in  order  to  maintain  nutrition.  A  tub-bath  followed 
by  a  dry  rub  should  be  given  daily.  The  bowels  must  not  be  allowed 
to  become  constipated,  and  moderate  exercise  should  be  encouraged. 

Drugs  Advised. — For  five  successive  days  out  of  each  month  a 
patient  from  five  to  ten  years  old  should  be  given,  after  meals,  5  grains 
of  salicylate  of  soda  (wintergreen)  and  10  grains  of  bicarbonate  of  soda. 
This,  with  the  low  meat  and  low  sugar  diet,  is  usually,  but  not  invari- 
ably, sufficient  to  prevent  a  recurrence.  Occasionally  I  have  been 
obliged  to  give  the  above  treatment  for  five  days  with  intervals  of 
only  ten  days.  An  interesting  result  of  this  treatment  has  been  an 
entire  disappearance  of  the  growing  pains,  recurrent  bronchitis,  or 
low  grade  eczema,  with  which  the  child  may  have  been  afflicted. 

Drugs  Used  With  Caution. — The  further  management  of  valvular 
disease  depends  to  a  certain  degree  upon  the  location  and  nature  of  the 
lesion.  Because  a  child  has  a  cardiac  lesion  he  does  not  necessarily 
require  digitalis.  Not  a  little  harm  is  done,  in  the  treatment  of  diseases 
in  children,  by  giving  powerful  drugs  when  they  are  not  indicated.  Too 
often  in  heart  disease  the  physician  feels  his  duty  done  when  he  gives 
digitalis.  Many  times  I  have  seen  children  taking  digitahs  and  strych- 
nin because  of  some  cardiac  lesion,  while,  at  the  same  time,  they  were 
suffering  from  constipation,  recurrent  respiratory  disorders,  and  per- 
sistent indigestion  due  to  dietetic  errors,  all  of  which  had  escaped  the 
attention  of  the  physician. 

Mitral  Regurgitation. — In  mitral  regurgitation,  well  compensated, 
the  activities  need  be  but  little  curtailed;  in  fact,  the  patient  may  be 
encouraged  to  indulge  in  outdoor  exercise,  although  competition  in  all 
games  requiring  unusual  exertion,  tests  of  speed  or  endurance  of  any 
nature,  such  as  running  and  racing,  should  be  forbidden.  When  the 
patient  is  old  enough,  swimming,  bicycling,  horseback-riding,  and  golf 
may  be  advised.  Boys,  on  arriving  at  the  tobacco  and  alcohol  age, 
must  be  told  the  dangers  attending  the  use  of  either  drug,  and  both  must 
be  forbidden.  Girls  with  mitral  insufficiency  must  be  warned  against 
excessive  dancing,  rope-jumping,  tight  lacing,  and  indiscriminate 
eating.     For  patients  of  both  sexes,  rational  exercise  is  beneficial. 

Mitral  Stenosis  and  Aortic  Disease. — When  the  aortic  valves  are 
involved  either  in  insufficiency  or  stenosis,  or  when  there  is  a  consider- 
able degree  of  mitral  stenosis,  the  child 's  activities  should  be  consider- 
ably limited.  Under  these  conditions,  with  a  view  to  the  future,  re- 
gardless of  satisfactory  existing  compensation,  I  forbid  the  bicycle, 
swimming,  dancing,  baseball,  or  any  sport  or  game  which  may  call  for 
much  physical  effort.  Plenty  of  entertainment  may  be  provided  which 
does  not  call  for  great  physical  effort.  The  nature  of  the  disease  should 
be  fully  explained  not  only  to  the  parents,  but  also  to  the  patient,  when 


392  THE    PRACTICE    OF    PEDIATRICS 

the  latter  is  old  enough  to  understand,  so  as  to  secure  hearty  coopera- 
tion in  governing  the  child's  activities.  Moreover,  parents  should  be 
told  particularly  that  tonsillitis  or  angina  is  a  danger-signal,  and 
that,  on  the  occurrence  of  either  condition,  the  saHcylates  are  to  be 
brought  into  use  at  once,  even  before  the  physician  is  summoned. 

Ordinarily,  it  is  not  well  to  talk  over  a  child 's  ailments  with  him  or 
in  his  presence.  To  older  children  with  cardiac  disease,  however,  I 
explain  as  clearly  as  possible  the  nature  of  the  illness,  and  insist  that 
certain  measures,  particularly  such  as  relate  to  restriction  of  activity, 
shall  be  carried  out  indefinitely.  I  find  that  in  this  way  better  coopera- 
tion on  the  part  of  the  patients  is  secured  than  if  they  are  simply  given 
a  list  of  dogmatic  "don'ts."  It  is,  furthermore,  my  custom,  in  cases 
showing  aortic  involvement  or  mitral  stenosis,  to  advise  what  is  known 
as  "heart  rest."  Every  day  after  the  midday  meal,  with  clothing 
off  or  loosened,  the  child  should  be  made  to  rest  in  a  recumbent  posi- 
tion for  at  least  one  hour.  During  this  time  he  may  sleep  or  read,  as 
best  suits  his  individual  taste. 

Constructive  Medication. — As  most  of  the  cases  of  valvular  disease 
in  children  are  of  rheumatic  origin,  it  will  be  found  that  the  majority 
of  the  patients  are  suffering  from  a  mild  degree  of  anemia.  All  the 
benefits  of  good  nutrition,  fresh  air,  and  regularity  in  living  referred  to 
under  Tardy  Malnutrition  (p.  100),  should  be  afforded  these  children. 
Iron  alone  or  with  arsenic  is  here  of  some  value  when  given  with  a  suit- 
able diet.  A  method  often  followed  is  to  give,  for  five  days,  the 
salicylate  and  bicarbonate  of  soda  already  referred  to ;  for  fifteen  days 
iron  and  arsenic;  and  during  the  remaining  ten  days  of  each  month  no 
medication,  unless  cod-liver  oil  is  well  borne,  in  which  case  this  may 
well  be  given  in  combination  with  the  extract  of  malt.  If  the  patient 
can  swallow  a  capsule,  the  following  is  given: 

I^    Liquoris  potassii  arsenitis gtt.  xc 

Extract!  ferri  pomati gr.  x 

Quininae  bisulphatis 3j 

M.  ft.  capsulae  no.  xxx. 

Sig. — One  after  each  meal. 

If  the  iron  produces  constipation,  j-'s  to  }4  grain  of  the  extract  of 
cascara  may  be  added  to  each  capsule. 

Heart  Stimulants. — Aside  from  such  tonic  medication,  drugs  af- 
fecting the  heart  itself  should  not  be  given  unless  compensation  faUs. 
This  may  take  place  temporarily,  regardless  of  the  nature  of  the  lesion, 
after  some  forbidden  exercise,  or  during  an  acute  illness  sufficient  to 
produce  prostration.  Such  failure  may  occur  permanently  in  cases 
which,  for  any  reason,  do  badly.  In  the  event  of  defective  com- 
pensation and  dilatation,  the  child  should  be  kept  in  bed  until  the 
normal  heart  action  is  restored  by  rest,  or  until  it  is  demonstrated  that 
the  aid  of  heart  stimulants  is  required.  In  these  cases,  particularly 
in  those  of  the  latter  type,  when  there  is  a  rapid,  irregular  pulse,  dif- 
ficult breathing  or  excitement,  and  dropsy,  the  time-honored  remedy, 
digitalis,  is  to  be  brought  into  use.     For  children  I  prefer  to  use  the 


ADHERENT    PERICARDIUM  393 

tincture.  To  a  child  from  five  to  ten  years  old  from  3  to  5  drops  may 
be  given  after  meals  three  or  four  times  daily.  This  drug,  because 
of  its  well-known  irritant  effects  upon  the  stomach,  should  be  given 
considerably  diluted.  Its  beneficial  effects  will  be  apparent  first  in 
the  relief  of  the  dyspnea,  the  pulse  becoming  regular  and  of  increasing 
volume;  and  later  in  the  increased  secretion  of  the  kidneys  and  the 
disappearance  of  the  edema.  The  amount  of  digitalis  given  should  be 
reduced  as  soon  as  the  condition  will  allow,  but  the  medicine  should 
be  continued  for  a  considerable  time  after  the  patient  is  up  and  about. 
The  only  contraindication  to  the  use  of  digitalis  in  children  is  its  effect 
upon  the  stomach.  This  is  often  so  unfavorable  that  loss  of  appetite 
results,  in  which  case  the  preparations  should  be  discontinued.  In 
this  event  the  tincture  of  strophanthus,  which  is  referred  to  repeatedly 
in  this  work  as  a  heart  stimulant,  may  be  substituted  in  the  same  doses. 
In  cases  requiring  a  cardiac  stimulant  for  a  considerable  time  or 
permanently  I  have  had  satisfactory  results  by  alternating  the  digitalis 
with  the  strophanthus,  giving  each  for  five  days.  The  child,  however, 
who  requires  constant  cardiac  stimulation  promises  but  little  for  the 
future,  and,  in  my  experience,  few  patients  of  this  type  have  survived 
the  eighteenth  year. 

ADHERENT  PERICARDIUM 

As  a  result  of  an  unresolved  pericarditis  with  which  a  myocarditis 
may  or  may  not  have  been  associated,  adhesions  exist  which  bind  the 
pericardium  to  the  heart  muscle,  in  most  instances  completely  obHter- 
ating  the  pericardial  sac.  The  condition  is  found  in  cases  in  which 
there  is  extensive  cardiac  disease,  such  as  hypertrophy,  dilatation, 
and  valvular  involvement. 

Diagnosis. — Diagnosis,  if  made  at  all,  is  usually  made  at  the  autopsy. 
The  diagnostic  sign  of  real  differential  value  is  a  restriction  of  the  chest- 
waU  in  the  interspace  corresponding  to  the  apex-beat.  Sometimes  per- 
manent cardiac  friction-sounds  may  be  heard,  and  there  usually  is  an 
increase  in  the  cardiac  dulness  to  the  right  over  the  sternum. 


X.  THE  BLOOD  AND  BLOOD  DISEASES 

BLOOD  IN  THE  NEWLY  BORN 

According  to  Schiff,  Perlin,  Carstanjen,  Scipiades,  and  Takasu, 
the  blood  of  a  new-born  babe  exhibits  numerous  characteristic  changes. 

1.  The  specific  gravity  averages  between  1.060  and  1.080,  but 
during  the  first  two  weeks  rapidly  sinks  to  its  lowest  point,  at  which  it 
usually  remains  until  the  end  of  the  second  year  of  life,  after  which 
it  rises  until  puberty,  the  average  thus  being  between  1.050  and  1.055. 

2.  The  percentage  of  hemoglobin  is  very  high — usually  between 
100  and  140  per  cent,  of  that  found  in  the  healthy  adult. 

3.  The  red  cells,  which  are  greatly  increased,  may  number  as  high 
as  7,550,000,  and  usually  above  5,000,000. 

4.  The  white  cells  are  also  increased,  in  one  case  numbering  36,000. 

5.  According  to  Carstanjen,  the  polymorphonuclears  number  73.4 
per  cent.,  as  compared  with  16.05  per  cent,  lymphocytes. 

6.  A  large  number  of  nucleated  red  cells  are  present  up  to  the  sixth 
day,  after  which  scarcely  any  are  to  be  found. 

The  variations  noted  become  less  marked  after  the  fourth  day. 
The  number  of  polynuclear  leukocytes  diminishes,  and  after  the  fourth 
day  the  percentage  of  the  various  kinds  of  leukocytes  is  fairly  constant 
during  the  first  few  months. 

It  is  suggested  that  many  blood-changes  observed  in  the  new- 
born are  due  to  the  lack  of  water,  a  considerable  amount  of  which  is 
lost  through  the  intestine  and  in  the  form  of  perspiration. 

BLOOD  IN  INFANCY  OR  CHILDHOOD 

Hemoglobin. — Throughout  the  period  of  infancy  and  childhood  the 
hemoglobin  is  lower  than  in  the  adult,  its  minimum  being  usually 
reached  between  the  third  month  and  the  second  year.  From  this 
point  it  gradually  increases  until  puberty.  The  average  hemoglobin 
of  childhood  is  between  65  per  cent,  and  85  per  cent.,  the  former 
being  considered  a  low  limit  for  a  healthy  child. 

Red  Cells. — The  average  number  in  infancy  is  from  4,000,000  to 
5,500,000,  and  in  later  childhood  from  4,000,000  to  4,500,000  (Hayem). 
In  the  blood  of  the  fetus  and  in  premature  infants  nucleated  cells  are 
seen,  but  in  later  infancy  their  presence  must  always  be  considered 
pathologic.  Formerly  their  occurrence  even  in  healthy  children  was 
considered  the  rule. 

Normal  White  Corpuscles. — In  health  the  following  varieties  are 
found : 

1.  Lymphocytes. — These  cells  are  smaller  (5  to  8  microns  in  diame-" 
ter),  or  larger  (8  to  10  microns),  than  the  red  blood-cells.  The 
nuclei  are  relatively  large,  round,  deeply  stained,  centrally  placed,  and 

394 


BLOOD    IN    INFANCY    OR    CHILDHOOD  395 

contain  one  or  two  nucleoli.  The  cells  may  be  deeply  notched,  es- 
pecially the  smaller  ones,  and  even  suggest  polymorphonuclear  cells, 
but  are  never  identical  in  appearance.  The  protoplasm  forms  a 
narrow  rim  around  the  nucleus  and  is  sometimes  reticulated.  The 
nucleus  stains  with  basic  dyes  more  faintly  than  the  protoplasm.  The 
larger  cells  of  this  group  have  an  irregularly  staining  nucleus  with  a 
chromatin  network  and  a  margin  of  faintly  granular  protoplasm. 
The  lymphocytes  constitute  from  40  to  60  per  cent,  of  the  leukocytes 
in  the  normal  infant's  blood. 

2.  Large  Mononuclears. — These  are  not  polymorphous  cells,  but 
contain  a  single  round  or  large  oval  nucleus,  and  are  usually  two  or 
three  times  as  large  as  red  blood-cells.  The  protoplasm  is  homogene- 
ous and  relatively  large  in  amount.  These  cells  constitute  about  4 
to  6  per  cent,  of  the  leukocytes. 

3.  Transitional  Cells.— These  are  usually  larger  than  the  large 
mononuclears,  which  they  closely  resemble;  in  fact,  they  are  the  largest 
cells  of  the  blood.  They  possess  a  "wallet"  or  "saddle-bag"  nucleus. 
During  the  first  few  months  they  comprise  8  to  10  per  cent,  of  the  white 
cells  (Carstanjen,  Karnizki). 

4.  Polymorphonuclear  Neutrophiles.— These  cells,  which  constitute 
from  18  to  40  per  cent.  (Emerson)  of  the  child's  blood,  are  somewhat 
smaller  than  the  transitional  cells.  The  nucleus  is  characterized  by  its 
polymorphous  nature  and  its  deep  stain,  while  its  protoplasm  is  well 
filled  with  neutrophile  granules,  which  may  cover  the  nucleus. 

5.  Eosinophiles. — These  are  usually  of  the  same  size  as  the  pre- 
ceding, and  occasionally  a  little  larger.  The  nuclei  are  fairly  well 
stained,  while  the  protoplasm  is  filled  with  large  eosinophilic  granules. 
These  cells  constitute  2  to  4  per  cent,  of  the  normal  white  cells. 

6.  Mast  Cells. — These  are  about  the  same  size  as  the  preceding, 
but  frequently  smaller;  they  have  a  trilobed  nucleus  and  a  protoplasm 
containing  many  large  basophilic  granules;  often  they  are  metachro- 
matic.    Their  proportion  is  about  0.5  per  cent,  of  the  white  cells. 

Leukocytes  Found  in  Pathologic  Conditions. — 

1.  Myelocytes. — While  any  cell  of  bone-marrow  is,  strictly  speaking, 
a  myelocyte,  by  this  term  is  generally  meant  one  with  a  round  nucleus 
and  a  granular  protoplasm.  Neutrophilic  and  eosinophilic  myelocytes 
occur.  Their  size  varies  from  that  of  the  large  mononuclears  to  that  of 
red  corpuscles.  The  nucleus  is  round,  oval,  and  sometimes  kidney- 
shaped,  but  never  polymorphous;  it  is  usually  centrally  placed,  and  is 
not  stained  diffusely  by  any  good  nuclear  dye.  The  protoplasm  may 
contain  many  or  few  granules  of  the  neutrophilic  type. 

2.  Eosinophilic  Myelocytes. — These  resemble  the  polynu clear  eosino- 
philes, except  for  the  rounded,  undivided  nucleus. 

In  pathologic  conditions  the  leukocytes  undergo  various  degrees  of 
degeneration,  both  acute  and  chronic.  There  may  be  swelling,  frag- 
mentation, and  hydropic  and  fatty  degeneration,  with  nuclear  changes. 

According  to  Rieder,  the  leukocytes  average  from  8700  to  12,400 
between  the  second  and  fourth  days;  after  the  fourth  day,  from  12,400 


396  THE    PRACTICE    OF    PEDIATRICS 

to  14,800.  In  infancy  the  variations  are  from  9000  to  14,000;  in  later 
childhood,  from  6000  to  12,000.  When  the  second  year  is  reached,  the 
blood  gradually  begins  to  assume  the  adult  type.  This,  however,  is 
not  attained  until  the  fifteenth  or  sometimes  the  twentieth  year.  Up 
to  the  sixth  year  there  is  a  preponderance  of  lymphocytes.  Sex  makes 
no  material  difference  until  the  fifteenth  year.  The  blood-making 
organs  of  the  infant  are  severely  affected  by  disease.  The  infantile  blood 
readily  takes  up  myelocytes  and  nucleated  cells  (Zelenski-Cybulski). 

Leukocjrtosis. — By  this  is  meant  an  increase  in  the  number  of  white 
corpuscles  in  the  blood.  It  may  be  of  two  varieties — relative  and  abso- 
lute. A  relative  leukocytosis  is  more  frequent  in  children  than  in 
adults.  By  the  leukocytosis  one  may  judge  the  nature  of  the  reaction 
of  the  organism  to  bacteria  or  to  the  toxins  in  the  blood  elaborated 
by  the  bacteria  concerned  in  the  inflammation  or  infection.  It  may 
thus  be  seen  that  the  reaction  of  the  individual  will  depend  upon 
two  factors:  (a)  the  severity  of  the  infection  and  (h)  the  resistance 
of  the  individual.  Of  the  two,  the  latter  is  more  important.  It  is  a 
fact  that  the  most  marked  degree  of  leukocytosis  is  observed  in  a 
healthy,  well-nourished  child  suffering  from  a  severe  infection ;  while, 
on  the  other  hand,  a  feeble  child  suffering  from  the  same  infection 
will  have  a  slight  leukocytosis  or  probably  none  at  all.  The  nature 
of  the  infection  depends  upon  the  character  of  the  inflammatory  process. 
Leukocytosis  is  less  marked  in  serous  and  more  pronounced  in  suppu- 
rative processes,  while  in  both  instances  it  is  highest  during  the  stage 
of  active  exudation.  In  well-localized  suppurative  inflammations 
there  may  be  no  leukocytosis  at  all. 

Leukocytosis  is  present  in  a  great  many  pathologic  conditions,  and 
in  some  cases  the  explanation  is  wanting.  A  satisfactory  division  of 
leukocytosis  is  into  the  two  groups — (a)  physiologic  and  (6)  pathologic. 
By  the  former  is  meant  that  which  follows  a  meal  or  exercise  or  that 
which  occurs  in  the  new-born ;  by  the  latter  is  meant  that  which  may 
occur  after  serious  hemorrhage,  maligant  disease,  and  various  inflam- 
matory and  toxic  conditions.  Japha  has  not  been  able  to  demonstrate 
a  genuine  leukocytosis  of  digestion  in  the  bottle-fed  infant,  and  Greger 
did  not  even  find  it  regularly  present  in  the  breast-fed  infant.  If,  how- 
ever, a  breast-fed  infant  was  given  cow's  milk,  there  was  an  immediate 
occurrence  of  leukocytosis  and  hence  the  opinion  (Moro)  that  it  is  a  re- 
action against  foreign  proteid.  Children  show  a  more  pronounced 
digestive  leukocytosis  than  adults,  occasionally  the  increase  amount- 
ing to  one-third  of  the  total  number  of  leukocytes. 

The  chief  form  of  leukocytosis  in  children  is  the  inflammatory  type. 
This  is  especially  noticeable  in  acute  pneumonia,  diphtheria,  acute 
rheumatism,  erysipelas,  scarlet  fever,  tuberculous  meningitis,  and  in 
suppurative  conditions  of  the  subcutaneous  tissues,  serous  cavities, 
bones,  joints,  and  viscera.  In  these  conditions  the  increase  is  chiefly 
in  the  polymorphonuclear  neutrophils. 

In  pertussis,  hereditary  syphilis,  and  certain  diseases  of  the  spleen 
there  is  a  relative  increase  in  the  lymphocytes,  while  in  leukemia, 


THE   BLOOD    IN    DIFFERENT    DISEASES  397 

asthma,  helminthiasis,  and  some  forms  of  chronic  skin  disease  there 
is  an  increase  in  the  eosinophils. 

There  is  usually  no  leukocytosis  in  typhoid  fever,  measles,  rotheln, 
mumps,  malaria,  and  uncomphcated  tuberculosis  not  invading  the 
meninges  or  serous  surfaces.  In  the  usual  forms  of  gastro-enteritis 
leukocytosis  is  absent,  while  in  "  Finkelstein 's  alimentary  food  intoxica- 
tion" it  is  pronounced. 

THE  BLOOD  IN  DIFFERENT  DISEASES 

Pneumonia. — In  this  disease  there  is  regularly  a  leukocytosis,  and 
it  is  in  this  illness  that  the  inflammatory  leukocytosis  has  best  been 
studied.  The  leukocytosis  here  is  an  expression  of  the  resistance  of 
the  organism  to  the  infection,  and  depends  but  little  on  the  fever  and 
the  extent  of  consolidation  (Ewing).  In  an  average  case  the  count  may 
vary  between  15,000  and  40,000  or  50,000,  and  but  rarely  reaches 
100,000;  although  there  are  a  number  of  cases  on  record  with  a  count 
as  high  as  this.  A  high  count  gives  no  idea  of  prognosis ;  it  means  that 
the  protective  forces  are  making  a  vigorous  fight,  but  gives  no  hint 
as  to  which  will  win,  they  or  the  infection.  Absence  of  leukocytosis  is 
usually  of  bad  import,  and  shows  that  the  patient  has  low  resistance; 
and  a  rapid  fall  with  either  a  low  or  a  high  temperature  is  usually 
indicative  of  a  loss  of  resistance  on  the  part  of  the  patient.  The  fall 
in  the  count  begins  just  before,  just  after,  or  with,  that  of  the  tempera- 
ture, and  may  be  by  the  maximum  count;  this  diminution  usually 
corresponds  to  the  change  in  temperature.  If  the  count  remains  ele- 
vated, delayed  resolution,  empyema,  or  abscess  should  be  suspected. 
The  increase  is  mainly  in  the  polymorphonuclear  cells,  which  may  vary 
from  60  to  90  per  cent,  of  the  total  leukocytes.  In  pneumonia  following 
pertussis  the  increase  is  chiefly  in  the  lymphocytes.  The  absence  of  a 
leukocytosis  in  a  strong,  well-nourished  child  who  is  very  ill  is  always 
strong  presumptive  evidence  against  pneumonia.  The  changes  in  the 
red  cells  and  hemoglobin  are  those  of  a  secondary  anemia,  depending 
on  the  duration  of  the  disease  and  the  resistance  of  the  patient. 

Leukocytosis  is  present  in  both  forms  of  pneumonia  in  infancy  and 
childhood,  but  is  more  marked  in  the  lobar  form,  the  number  of  leu- 
kocytes to  the  cubic  millimeter  being  about  twice  as  many  as  in  the 
catarrhal  types.  There  is  marked  leukocytosis  in  the  fatal  cases  of 
both  forms  of  pneumonia  (Koplik). 

Empyema. — Marked  leukocytosis  is  almost  invariably  present  with 
a  high  polymorphonuclear  count — usually  from  75  to  90  per  cent.  In 
cases  of  long  standing  there  is  often  no  leukocytosis,  but  the  poly- 
morphonuclear count  remains  elevated.  In  tuberculous  effusions  the 
count  is  usually  low,  with  no  increase  in  the  polymorphonuclear  count. 

Influenza. — Uncomplicated  influenza  has  no  leukocytosis.  In- 
fluenzal pneumonia  ordinarily  has  a  leukocytosis  of  from  15,000  to  20,- 
000.  To  date  no  uniform  conclusions  have  been  arrived  at  concerning 
any  characteristic  change  in  the  differential  count  other  than  that  of 
an  ordinary  pneumonia. 


398  THE    PRACTICE    OF    PEDIATRICS 

Tuberculosis. — In  tuberculosis,  in  general,  there  exists  a  mild  grade 
of  chlorotic  anemia  with  little  or  no  leukocytosis.  The  count  is  nearly 
normal,  while  the  hemoglobin  is  somewhat  reduced.  In  other  cases 
there  is  a  Ijanphocytosis,  absolute  or  relative.  If  a  secondary  infection 
occurs,  which  is  not  infrequent  in  infants  and  young  children,  leukocy- 
tosis is  the  rule,  and,  in  fact.  Limbeck  considers  the  presence  of  a 
leukocytosis  sufficient  guarantee  of  a  secondary  infection.  In  case  of 
pneumonia  the  leukocytosis  is  as  high  as  in  the  ordinary  croupous 
pneumonia.  Various  observers  are  of  the  opinion  that  in  incipient 
tuberculosis  there  is  a  slight  increase  in  the  eosinophiles,  and  that,  as 
the  infection  progresses,  they  diminish.  From  a  series  of  182  blood 
examinations  of  tuberculous  patients  Solis-Cohen  concludes  that  an 
increase  in  the  polynuclear  count  points  toward  an  advance  of  the 
disease  and  vice  versa.  In  tuberculous  bronchial  adenopathy  and 
peritonitis,  leukocytosis  is  absent,  although  in  the  latter  Cabot  reports 
an  increase  in  the  cell  count  in  14  out  of  60  cases.  Tuberculous  men- 
ingitis regularly  causes  a  leukocytosis,  reaching  at  times  as  high  as 
50,000,  while  there  is  usually  a  polymorphonucleosis,  in  some  instances 
as  high  as  90  per  cent,  of  the  total  white  cells.  In  bone  and  joint 
disease  the  leukocytes  are  normal  or  very  slightly  increased,  and  only 
during  abscess  formation  or  following  operation  is  there  an  appreciable 
increase  in  the  cell  count. 

Typhoid. — As  in  adults,  there  is  a  low  white  cell  count,  generally 
under  10,000.  The  lymphocytes  are  slightly  increased,  and  there  is 
usually  a  mild  grade  of  anemia. 

Rheumatism. — There  is  regularly  a  leukocytosis  and  a  severe  grade 
of  secondary  anemia. 

Peritonitis  and  Appendicitis. — In  the  former  there  is  a  polymorpho- 
nuclear leukocytosis.  This,  however,  is  wanting  in  some  cases  of  the 
severest  type.  In  a  series  of  70  cases  of  appendicitis  in  children  re- 
ported by  Fowler  in  1912,  the  average  leukocyte  count  was  19,106, 
the  average  polynuclear,  79.7  per  cent.;  the  highest  leukocyte  count 
was  48,200;  the  lowest,  8200;  the  highest  polynuclear  count,  92  per 
cent. ;  the  lowest,  63  per  cent. 

Meningitis. — In  cerebrospinal  meningitis  and  in  meningitis  caused 
by  the  other  pyogenic  organisms  there  is  regularly  a  leukocytosis  with 
an  increase  in  the  polymorphonuclears.  The  leukocyte  count  is  of  no 
value  in  distinguishing  the  various  forms  of  meningitis,  since  it  is  also 
present  in  the  tuberculous  form  (Emerson). 

Poliomyelitis. — Until  a  monograph  on  poliomyelitis  by  Draper, 
Peabody,  and  Dochez,  of  the  Rockefeller  Institute,  was  issued,  a  num- 
ber of  conflicting  statements  had  been  made  concerning  the  blood 
findings  in  this  disease.  Previous  to  this  clinical  study  by  the  above 
authors,  Miiller  in  Germany,  and  La  Fetra  in  New  York,  had  made  the 
most  extensive  observations.  The  latter  reported  a  leukocytosis 
between  13,400  and  20,600,  while  Miiller  found  a  leukopenia  in  the 
acute  stage.  Draper,  Peabody,  and  Dochez  tabulated  their  findings  in 
59  hospital  cases,  and  came  to  the  conclusion  that  in  the  preparalytic 


THE   BLOOD    IN    DIFFERENT    DISEASES  399 

stage  the  counts  varied  within  the  normal,  but  that  there  was  a  tendency 
toward  a  leukocytosis.  In  the  acute  stage,  in  every  case  except  one  in 
which  leukopenia  existed,  there  was  a  marked  leukocytosis,  in  several 
instances  reaching  as  high  as  30,000.  In  addition  to  this  increase  in 
the  white-cell  count  they  found  a  constant  increase  in  the  polymorpho- 
nuclears of  10  to  15  per  cent,  and  a  diminution  of  lymphocytes  of  15  to 
20  per  cent.  The  other  white  cells  showed  no  abnormalities.  In 
view  of  these  findings  a  definite  leukocytosis  with  an  increase  in  the 
polymorphonuclears  and  a  corresponding  diminution  of  the  lympho- 
cytes is  additional  evidence,  when  considered  with  other  available 
signs,  in  favor  of  the  disease  in  question. 

Eosinophilia. — Asthma. — In  true  bronchial  asthma  the  eosinophiles 
may  be  from  10  to  20  per  cent.  Cases  are  reported  with  eosinophilia 
as  high  as  50  per  cent.  Holt  gives  10.7  per  cent,  as  the  average  in  a 
series  of  cases  examined  in  his  clinics  by  Wile ;  the  highest  was  26  per 
cent.  The  presence  of  an  eosinophilia  serves  to  distinguish  the  attack 
from  one  of  acute  bronchitis  or  tuberculosis.  The  occurrence  of  an 
increase  in  the  eosinophiles  apparently  determines  the  asthmatic  char- 
acter in  certain  spasmodic  attacks  of  the  respiratory  system  in  infancy. 

Eczema. — -There  is  no  difference  between  the  number  of  eosino- 
philes in  infancy  and  childhood  and  that  in  adult  life.  Occasionally 
an  eosinophilia  is  noted  in  pemphigus. 

Parasites. — Any  parasite,  from  the  harmless  pinworm  to  the  most 
mahgnant  uncinaria,  may  cause  eosinophilia.  It  is  not  always  present, 
nor  does  its  degree  bear  any  relation  to  the  severity  pf  the  infection  or 
the  danger  of  the  parasite.  The  presence  of  an  eosinophilia  in  a  child 
should  always  make  one  suspicious  of  intestinal  worms.  Amberg,  in 
amebic  dysentery  of  children,  found  a  slight  increase  in  the  eosinophile 
count.  The  average  number  of  these  cells  in  parasitic  diseases  is  from 
4  to  10  per  cent,  of  the  total  white-cell  count,  but  these  figures  naay  be 
exceeded.  In  not  a  few  cases  symptoms  of  pernicious  anemia  have 
been  present,  and  a  severe  grade  of  secondary  anemia  may  exist. 

In  a  recent  case  of  trichinosis  the  eosinophile  count  was  72  per  cent. 

Syphilis  (Congenital). — There  is  usually  a  relative  increase  in  the 
mononuclear  cells  and  a  severe  secondary  anemia,  while  a  case  with  a 
severe  rash,  especially  involving  the  face,  may  develop  an  eosinophilia 
as  high  as  23  per  cent.,  diminishing  as  the  condition  improves. 

Gastro-enteritis. — In  this  disease  there  is  usually  no  leukocytosis 
although  in  some  cases  a  slight  increase  may  be  noted.  It  is  remark- 
able that  even  in  long-standing  cases  of  gastro-enteritis,  enterocolitis, 
etc.,  there  is  not  a  great  reduction  in  hemoglobin. 

In  Finkelstein 's  "  Food  Intoxication"  one  of  the  cardinal  signs  is  a 
leukocytosis  of  from  20,000  to  40,000,  the  largest  cell  percentage  being 
of  the  polymorphonuclear  variety. 

Infectious  Diseases. — Whooping-coitgh. — In  this  disease  the  leu- 
kocytes are  increased  to  three  or  four  times  the  normal  amount,  averag- 
ing 40,000  (Emerson).  The  change  is  more  pronounced  the  younger 
the  child.     The  early  appearance  of  a  leukocytosis  is  important  in 


400  THE    PRACTICE    OF    PEDIATRICS 

diagnosis.  The  increase  is  chiefly  in  the  lymphocytes,  which  may 
constitute  from  60  to  80  per  cent,  of  the  total  white  count. 

According  to  Frohlich  and  Muenier,  the  leukocytosis  of  pertussis 
far  exceeds  that  of  any  other  afebrile  disease  of  the  respiratory  tract. 
The  leukocytosis  occurs  in  the  early  part  of  the  convulsive  stage,  dis- 
appears with  improvement,  and  does  not  seem  to  be  influenced  by 
complications. 

Measles. — Hecker  (Zeitschrift  fiir  Kinderheilkunde)  records  the 
results  of  his  blood  examination  of  14  children.  In  the  incubation 
period  his  observations  were  uniform,  and  he  concluded  that  during  the 
incubation  period,  and  occasionally  extending  into  the  eruptive  period, 
there  existed — (1)  a  leukopenia;  (2)  a  relative  lymphocytosis;  (3) 
reduction  in  the  number  of  eosinophiles.  In  13  cases  in  the  prodromal 
period  Platinger  found  a  neutrophile  hyperleukocytosis  of  even  20,000, 
which  rapidly  gave  place  to  a  hypoleukocytosis  during  the  eruptive 
stage.  Holt  states  that  there  is  a  leukocytosis  of  15,000  to  30,000, 
beginning  soon  after  infection  and  increasing  for  four  or  five  days.  A 
marked  increase  in  the  leukocytes  during  the  illness  usually  points  to  a 
complication.  Hektoen,  in  his  animal  experimentation  and  observa- 
tion on  human  beings,  found  that  there  was  a  preliminary  leukocytosis, 
followed  by  a  leukopenia,  chiefly  of  the  polymorphonuclear  neutro- 
philes,  the  lymphocytes  being  relatively  increased. 

Diphtheria. — In  this  disease  there  is  a  moderate  anemia,  a  loss  of 
about  2,000,000  red  cells  at  the  time  of  defervescence  (Emerson, 
Ewing).  The  reduction  in  the  hemoglobin  is  usually  proportionate  to 
the  reduction  in  the  red  cells,  ^here  is  usually  a  slight  leukocytosis, 
ranging,  as  a  rule,  from  10,000  to  15,000,  but  in  severe  cases  the  white 
cells  may  number  17,000  and  with  complications,  30,000  (Emerson). 
The  rise  is  in  the  polymorphonuclear  cells.  According  to  Engel,  the 
myelocytes  are  increased,  especially  in  the  fatal  cases,  from  3  to  16  per 
cent.  Morse  says,  "The  examination  of  the  blood  in  diphtheria  is  of 
no  practical  clinical  importance  in  diagnosis,  prognosis,  or  treatment." 

Scarlet  Fever. — Scarlet  fever  produces  little  change  in  the  red  blood- 
cells,  but  does  cause  a  slight  anemia  (Reckzan) ,  the  average  drop  being 
1,000,000.  There  is  uniformly  a  leukocytosis,  beginning  in  the  incu- 
bation period  and  continuing  into  convalescence  (Emerson).  The 
leukocytes  vary  from  10,000  to  40,000;  in  mild  cases  from  10,000  to 
20,000;  in  moderate  cases  from  20,000  to  30,000;  in  severe  cases  from 
30,000  to  40,000,  while  Holt  states  the  number  may  be  as  high  as  75,000. 
The  variation  is  according  to  the  severity  of  the  case.  The  increase  is 
chiefly  in  the  polymorphonuclear  cells,  which  may  constitute  85  to  98 
per  cent,  of  the  total  count,  especially  in  severe  and  sometimes  fatal 
cases.  At  first  there  is  a  complete  disappearance  of  the  eosinophile 
cells,  and,  later,  a  rapid  increase  (20  per  cent.).  The  disappearance  of 
the  eosinophile  cells  during  the  course  of  the  disease  is  a  bad  prognos- 
tic sign,  and  absence  of  leukocytosis  is  also  ominous. 

In  the  Centralblatt  fiir  Bakteriologie  of  November,  1911,  Dohle 
reported,  in  30  cases  of  scarlet  fever,  certain  inclusion  bodies  found 


BLOOD-PRESSURE    IN    CHILDREN  401 

chiefly  in  the  leukocytes.  More  recent  work  by  Nicoll,  of  New  York, 
and  Kolmer,  of  Philadelphia,  has  shown  that  these  bodies  are  present 
in  streptococcus  infections,  and  the  latter  reports  their  presence  in  42 
per  cent,  of  diphtheria  cases.  The  inclusion  bodies  are  present  in  94 
per  cent.  (Kolmer)  of  scarlet-fever  cases  during  the  first  three  days; 
after  this  they  diminish  in  number,  and  are  generally  absent  after  the 
ninth  day.  Thus,  while  their  diagnostic  value  is  necessarily  limited, 
their  presence  may  be  useful  in  the  differential  diagnosis  of  scarlet  fever, 
rotheln,  measles,  and  gastro-intestinal  rashes. 

Congenital  Heart  Disease. — Of  congenital  affections,  this  disease 
presents  the  largest  number  of  cases  of  polycythemia,  although,  as 
Osier  states,  ''polycythemia  is  not  a  constant  feature  in  congenital 
cyanosis.  It  is  characteristic  rather  of  the  later  stages  of  the  disease, 
and  its  appearance  is  said  to  be  of  unfavorable  prognosis."  Vaquez 
and  Quiserne  state  their  belief  that  when  the  polycythemia  reaches 
6,000,000,  it  seems  to  be  fatally  progressive,  evidencing  a  more  and  more 
insufficient  aeration,  the  prognosis  becoming  correspondingly  graver. 
The  red  cells  frequently  reach  6,000,000  to  7,000,000,  and  the  percent- 
age of  hemoglobin  may  be  as  high  as  160,  and  the  specific  gravity  1070; 
naturally  the  blood-clot  is  greatly  increased,  owing  to  the  excess  of  red 
blood-cells.  Cautley  reports  a  case  of  polycythemia  of  10,000,000,  and 
Still  one  of  9,280,000.     The  white  blood-cells  are  not  increased. 

BLOOD-PRESSURE  IN  CHILDREN 

During  the  past  few  years  numerous  observations  of  the  blood- 
pressure  in  different  diseases  have  been  made  by  Rolleston,  Sergeant, 
and  Hutinel,  abroad,  and  by  Rowland  and  Hoobler  in  America. 

Probably  the  simplest  and  most  easily  handled  machine  of  the  Riva 
Rocci  type  is  the  Faught,  with  a  cuff  made  from  an  ordinary  Vorhees 
uterine  dilating  bag.  With  this  combination,  the  smallest  arm  can 
be  readily  accommodated.  An  exact  estimation  of  the  pressure  is  not 
always  possible  on  account  of  the  small  size  of  the  radial  artery  and  the 
overlying  thick  pad  of  fat,  which  makes  palpation  rather  difficult,  and 
especially  so  when  the  infant  struggles,  as  is  not  infrequently  the  case. 
The  Faught  instrument  gives  readings  usually  from  5  to  10  mm.  higher 
than  other  sphygmomanometers,  and  in  practically  every  instance  the 
personal  equation  is  an  important  factor. 

Hoobler,  of  New  York,  has  recently  improved  upon  the  pith-ball 
arrangement,  so  that  it  automatically  and  visibly  indicates  both  sys- 
tolic and  diastolic  pressure,  thus  enabling  one  to  eliminate  variations 
due  to  the  personal  equation,  which  different  observers  have  shown  to 
be  considerable. 

According  to  Kolossowa,  Oppenheimer,  and  Bauchwitz,  the  follow- 
ing figures  may  be  considered  normal: 

Age,  Mm.  of 

Years  Mercury 

1-2 75-85 

3-4 85 

5-7 90-95 

8-10 95-100 

11-13 100-110 

26 


402  THE    PRACTICE    OF    PEDIATRICS 

All  febrile  diseases  tend  to  lower  the  blood-pressure.  During  the 
past  few  years,  Comby,  Hutinel,  and  Rolleston  have  found  a  constant 
hypotension  in  scarlet  fever  and  diphtheria,  more  pronounced  in  the 
former.  These  authors  consider  a  severe  degree  of  hypotension  to  be 
of  bad  omen,  especially  in  scarlet  fever,  and  they  believe  that  this  con- 
dition should  be  met  by  the  exhibition  of  adrenalin  hypodermically. 

Among  other  causes  of  hypotension,  Janeway  enumerates 
hemorrhage,  collapse,  and  the  action  of  poisonous  drugs,  especially 
chloroform. 

Rowland  and  Hoobler,  in  a  series  of  observations,  found  that  fresh 
air  in  pneumonia  tended  to  raise  the  blood-pressure,  and  that  removal 
of  the  patient  to  room  temperature  produced  a  corresponding  fall. 
This  rise  in  pressure  was  apparently  beneficial  in  every  case.  The 
blood-pressure  changes  were  not  so  pronounced  in  those  convalescing 
from  the  disease.  The  value  of  blood-pressure  estimation  in  epidemic 
meningitis  during  intraspinal  injections  of  serum  will  be  referred  to 
later. 

Increased  blood-pressure  is  furthermore  observed  in  conditions  of 
acute  cerebral  compression  and  anemia  and  in  acute  nephritis  com- 
plicated by  uremia. 

COAGULATION  TIME 

The  great  diversity  of  opinion  on  the  normal  coagulation  time  and 
also  in  various  diseases  has  no  doubt  been  due  to  the  variety  of  instru- 
ments employed;  however,  the  best  results  obtained  have  been  those  of 
Rudolf — 8.1  minutes — and  Carpenter — 9.5  minutes — working  with 
different  instruments. 

Owing  to  these  wide  variations,  despite  careful  technic  and  regula- 
tion of  apparatus,  no  constant  results  have  been  obtained.  From  a 
rather  exhaustive  study  Carpenter  and  Gittings  conclude  that  it  is 
improbable  that  any  important  variation  exists  in  the  coagulation  of 
the  blood  in  diseases  other  than  those  of  the  so-called  hemorrhagic 
type.  This  opinion  may  be  qualified  by  the  statement  that  average 
differences  of  one,  two,  or  three  minutes  can  hardly  be  construed  as 
of  any  practical  importance,  inasmuch  as  a  difference  of  from  five 
to  twelve  minutes  has  been  found  in  typhoid  fever  by  authoritative 
observers. 

ANEMIA 

Simple  anemia  is  usually  a  secondary  condition,  and  is  not  at  all  in- 
frequent in  children.  A  vast  majority  of  the  cases  coming  under  my 
observation  are  those  of  children  of  the  runabout  age,  and  older  chil- 
dren who  are  suffering  from  tardy  malnutrition,  having  been  badly  fed 
and  having  wasted  their  energy  in  different  ways.  Simple  anemia  may 
be  the  result  of  hemorrhage,  as  in  hemorrhagic  disease  in  the  newly 
born  and  in  purpura,  particularly  purpura  fulminans  (Henoch's).     In 


ANEMIA  403 

the  average  case  of  anemia  in  my  own  work  the  hemoglobin  ranges  from 
40  to  50  per  cent.,  and  the  red  cells  from  3,500,000  to  4,000,000. 
Children  suffering  from  tuberculosis  and  syphilis  usually  show  a  secon- 
dary anemia.  It  is  also  temporarily  present  after  pneumonia,  scarlet 
fever,  diphtheria,  and  typhoid  fever,  and  similar  diseases  which  have 
severely  taxed  the  organism. 

I  have  seen  a  great  many  cases  in  runabout  children  under  three 
years  of  age,  for  whom  the  milk  diet  had  been  continued  as  the  almost 
exclusive  means  of  nourishment.  Children  of  the  poor,  because  of  the 
defective  feeding  and  housing,  are  frequent  sufferers. 

Symptoms. — The  chief  symptom  is  that  of  weakness.  The  appe- 
tite is  usually  indifferent,  and  the  bowels  are  constipated.  Such 
children  tire  readily,  and  are  unable  to  keep  up  with  their  fellows  at 
play  or  in  school.  They  sleep  poorly,  and,  as  a  rule,  are  irritable  and 
unhappy.  In  appearance  they  are  apt  to  be  pale  and  thin,  although 
this  is  not  invariably  the  case,  as  I  have  repeatedly  seen  severe  anemia 
in  plump  children. 

Illustrative  Case. — A  very  pronounced  case  coming  under  my  care  was  that 
of  a  boy  of  six  years  who  weighed  46K  pounds.  The  blood  examination  showed: 
hemoglobin,  18  per  cent.;  red  cells,  660,000.  In  two  weeks  the  hemoglobin  was 
20  per  cent.;  the  red  cells,  640,000.  Five  weeks  after  first  examination,  the  hemo- 
globin was  30  per  cent.;  red  cellg,  1,172,000.  The  blood  examination  was  checked 
up  by  a  second  person.  No  further  improvement  had  taken  place  after  one  year 
of  treatment.  It  was  impossible  to  raise  the  blood  above  30  per  cent,  hemoglobin 
and  1,500,000  red  cells. 

Anemic  murmurs  may  be  heard  over  the  heart,  but  this  has  been 
unusual  in  my  cases.  In  the  case  referred  to,  the  heart-sounds  were 
normal.     The  spleen  is  not  often  found  enlarged. 

Examination  of  the  blood  in  this  disease  (or  symptom)  enables  one 
to  estimate  with  accuracy  the  severity  of  the  process.  In  mild  cases 
there  may  be  only  a  reduction  in  hemoglobin,  and  the  blood  may 
assume  the  chlorotic  type.  There  is,  in  addition,  a  reduction  in  the 
specific  gravity,  depending  on  the  degree  of  anemia,  and  if  the  primary 
affection,  like  pneumonia,  causes  an  increase  in  the  leukocytes,  there 
will  be  a  leukocytosis.  In  the  cases  of  moderate  severity  the  red  cells 
may  range  between  3,500,000  and  4,000,000,  and  the  hemoglobin 
from  40  to  60  per  cent.  In  severe  cases  the  red  cells  vary  from 
2,000,000,  or  a  little  less,  to  3,000,000.  There  is  a  corresponding  re- 
duction in  the  hemoglobin.  The  more  marked  the  reduction  in  red 
cells  and  hemoglobin,  the  more  marked  will  be  the  poikilocytosis  and 
polychromatophilia,  and  the  greater  the  number  of  normoblasts  and 
megaloblasts.  In  the  severe  cases  myelocytes  may  be  present.  There 
is  no  increase  in  the  eosinophile  cells.  In  the  severe  secondary  anemias, 
the  physical  characteristics  of  the  blood  are  very  striking.  It  may  be 
so  thin  as  to  separate  on  puncture  into  a  reddish  and  a  colorless  portion, 
resembling  beef- water  (Koplik). 

The  prognosis  is  good  in  the  cases  in  which  syphilis  and  tuberculosis 
are  absent.  In  fact,  the  greater  majority  of  the  cases  respond  most 
satisfactorily  to  properly  directed  treatment. 


404 


THE    PRACTICE    OF    PEDIATRICS 


Treatment. — The  management  consists  in  placing  the  child  in  a 
normal  child's  environment,  which  includes  the  giving  of  suitable  food. 
The  treatment  described  under  Tardy  Malnutrition  (p.  100)  covers 
these  cases. 

In  pronounced  cases  transfusion  offers  the  most  prompt  results. 

Management  of  Secondary  Anemia  through  Blood  Transfusion  by  the 
Lindemann  Method.— SignaWy  satisfactory  results  have  been  obtained  by 
this  method  of  treatment.  Infants  with  hemoglobin  under  25  per 
cent.  (Dare)  and  red  cells  under  2,500,000  have  been  permanently 
cured  by  one  transfusion.  So  satisfactory  have  been  my  results 
that  I  now  employ  transfusion  in  all  cases  that  fail  to  make  a  reason- 
ably satisfactory  response  to  other  measures. 

The  following  table  gives  in  a  concise  manner  the  results  of  trans- 
fusion in  8  cases: 


Blood  before  Transfusion 

Blood  after  Transfusion 

K 

o 

g 

to 
< 

'S 

Hgl,  per  cent. 

d 

Amount 
transfused, 
c.c. 

O 

a 
a 
o 

a, 

a 

6 

(D 

XS 
C 

o 

ft 

d 
CQ 

5 

V 

Sahli 

Sahli 

Fleischl 

F 

12    12.5 

14 

2,400,000 

175 

24 

45 

5,120,000 

17 

70 

4,000,000 

26.8 

Sahli 

Sahli 

Fleischl 

F 

18 

24.0 

37 

3,900,000 

200 

24 

55 

5,760,000 

14 

90 

5,000,000 

32.0 

j 

Sahli 

Sahli 

Dare 

M 

12     16.4 

32 

4,480,000 

300 

24 

78 

5,150,000 

3 

60 

3,840,000 

19,5 

1 

6 

52 

4,400,000  22.2 

! 

12 

63 

5,000,000j25.5 

18 

65 

5,000,000  28.0 

Sahli 

Sahli 

Dare 

1 

F 

23 

15.10 

20 

2,800,000 

140 

24 

55 

3,100,000 

1 

37 

2,700,000jl6.7 

24 

16.7 

30 

200 

24 

90 

4,320,000 

7 

19.8 

Sahli 

Sahli 

Dare 

F 

0 

11.0 

37 

1,600,000 

150 

24 

85 

4,000,000 

7 

65 

4,800,000 

19.5 

Dare 

Dare 

Dare 

M 

10 

12.5 

33 

4,300,000 

200 

24 

58 

4,900,000 

1 

58 
Died  of 
later. 

5,000,000  j  12. 8 
meningitis,  3  mo. 
Blood  count  nor- 

1 

mal,    g 

eneral     condition 

good. 

Sahli 

Sahli 

Dare 

F 

12 

12.4 

35 

3,120,000 

170 

24 

62 

4,040,000 

1 
3 
6 

50 
50 
56 

5.320,000 
4,100,000 
4,400,000 

14.0 
17.4 
19.8 

Sahli 

Sahli 

Dare 

M 

16 

21.0 

35 

3,300,000 

200 

24 

55 

3,400,000 

1 

60 

4,500,000 

24.8 

Fleischl 

i 

. 

6 

55 

4,100,000  25.12 

1 

CHLOROSIS  405 

CHLOROSIS 

Chlorosis  is  a  form  of  anemia  most  frequently  seen  in  young  girls  at 
the  time  of  puberty  or  later.  The  cause  of  the  condition  is  not  known. 
Various  theories  have  been  advanced,  none  of  which  can  be  proved. 
The  most  plausible  theory  assumes  the  existence  of  a  persistent  intes- 
tinal intoxication.  That  such  is  a  probable  cause  has  been  suggested  in 
my  cases.  The  more  pronounced  changes  occur  in  the  specific  gravity 
of  the  blood,  and  correspondingly  in  the  hemoglobin,  both  of  which  are 
reduced  out  of  proportion  to  the  reduction  in  red  cells,  although  in 
severe  cases  the  red-cell  count  may  fall  to  1,000,000.  In  ordinary  cases 
the  corpuscles  vary  between  3,000,000  and  4,500,000,  while  the 
hemoglobin  may  be  as  low  as  30  per  cent.  There  is  no  leukocytosis, 
but  microcytosis,  poikilocytosis,  and  polychromatophilia  are  usually 
present. 

Symptoms. — The  symptoms  are  quite  characteristic.  The  patient 
is  habitually  tired  and  incapable  of  unusual  or  prolonged  exertion. 
The  skin  is  of  a  peculiar  sallow,  greenish  color.  The  hands  and  the  feet 
are  cold.  Amenorrhea  is  almost  always  noted  in  girls  who  have  passed 
the  period  of  puberty.  I  have  known  the  menses  to  be  discontinued  for 
a  year.  The  appetite  is  capricious,  and  the  patient  craves  most  un- 
suitable articles  of  food  and  substances  not  in  the  food  class.  The 
history  usually  includes  the  story  of  habitual  constipation  which  was 
never  treated. 

Anemic  heart  murmurs  and  the  venous  hum  over  the  vessels  of  the 
neck  are  usually  present.  The  patient  is  nervous,  irritable,  and  not  in- 
frequently hysteric.  I  have  seen  one  pronounced  case  of  hystero- 
catalepsy  in  a  young  girl  with  chlorosis. 

Prognosis. — While  this  condition  is  usually  obstinate,  the  outcome 
in  my  cases  has  always  been  favorable. 

Treatment. — The  management  consists  in  the  correction  of  the  con- 
stipation and  in  the  provision  of  suitable  food  at  definite  intervals. 
Eating  between  meals  must  not  be  allowed.  Stress,  both  physical  and 
mental,  is  to  be  avoided.  Iron  and  arsenic  are  of  value.  The  follow- 
ing combination  of  drugs  has  served  me  well : 

I^     Strychninse  sulphatis gr.  J4 

Acidi  arsenosi gr.  M 

Extract!  ferri  pomati gr.  vj 

Extract!  cascarae  sagrada; gr.  xxx 

Chinise  bisulphatis gr.  Ix 

M.  ft.  capsulai  no.  xxx. 

Sig. — One  after  meals. 

The  amount  of  cascara  prescribed  depends  upon  the  degree  of 
constipation. 

After  the  diet  and  the  bowel  habit  have  been  satisfactorily  adjusted, 
the  patient  should  be  given  a  change  of  environment.  I  know  of 
nothing  so  conducive  to  a  reasonably  prompt  cure  as  an  absolute 
change  in  the  daily  life  of  the  patient. 

Entertainment  and  amusements  which  do  not  excite  or  overtax  are 


406  THE    PRACTICE    OF    PEDIATRICS 

to  be  encouraged.     The  cure  will  be  aided  by  removal  of  the  patient 
from  the  association  of  persons  who  are  not  congenial. 

PSEUDOLEUKEMIC  ANEMIA  OF  VON  JAKSCH 

In  this  affection  there  is  marked  anemia  with  enlargement  of  the 
spleen.  The  condition  was  first  described  by  von  Jaksch,  who  believed 
it  to  be  a  clinical  entity.  The  disease  represents  an  unusually  severe 
type  of  secondary  anemia,  and  is  of  toxic  origin,  the  nature  of  which  is 
not  understood. 

There  are  no  valid  grounds  for  believing  so  rare  a  disease  to  be 
dependent  upon  rachitis  or  syphilis.  Syphilis  and  rachitis  occur  with 
the  greatest  frequency.  If  these  diseases  were  causative  factors,  it  is 
reasonable  to  suppose  that  there  would  be  many  more  cases.  The 
great  majority  of  the  cases  follow  prolonged  intestinal  disturbance  and 
malnutrition. 

Pathology, — The  pathologic  changes  comprise  enlargement  of  the 
spleen  and  moderate  swelling  of  the  lymph-nodes,  with  a  diminution  in 
the  specific  gravity,  the  hemoglobin,  and  the  number  of  red  cells  in  the 
blood,  and  an  increase  in  the  leukocytes. 

The  Blood. — The  number  of  red  cells  is  frequently  as  low  as 
2,000,000.  It  may  fall  to  800,000.  The  color  index  is  low.  The 
hemoglobin  reduction  is  very  great,  and  may  reach  30  per  cent. 
(Emerson,  Comby,  Cautley).  There  is  always  a  leukocytosis  of  from 
20,000  to  50,000.  In  one  case  reported  by  Emerson  the  leukocytes 
numbered  114,000,  and  in  another,  at  the  Babies'  Hospital,  96,000. 
They  may  show  an  increase  in  the  mononuclear  or  polynuclear 
forms.  The  eosinophiles  are  usually  increased,  but  may  be  normal  or 
diminished.  The  white  cells  exhibit  great  variety  in  size,  shape, 
and  staining  properties.  Mast  cells  and  myelocytes  in  small  numbers 
may  be  found.  Karyokinesis  is  common,  and  is  regarded  by  some 
observers  as  of  diagnostic  importance  (Comby) .  The  red  cells  include 
many  microcytes,  myelocytes,  normoblasts,  and  megaloblasts,  and 
show,  in  addition,  poikilocytosis  and  polychromatophilia. 

Symptoms. — The  symptoms  are  those  of  progressive,  pronounced 
anemia  in  a  child  usually  well  nourished.  Emaciation  may  develop 
later  in  the  disease.  The  patient  becomes  very  weak  and  his  activities 
cease. 

The  appetite  is  often  greatly  impaired,  and  food,  if  urged,  is  apt  to 
be  vomited.  In  the  later  stages  hemorrhages  from  the  mucous  surfaces 
may  occur.  Petechise  are  common.  The  lymph-nodes  show  moderate 
enlargement. 

Fever  is  occasionally  present,  usually  due  to  intestinal  conditions. 

Probably  the  best  recent  discussion  of  this  condition  is  that  of 
Cabot,  who  thinks  that  the  many  very  different  cases  thus  diagnosed 
cannot  be  grouped  together. 

Prognosis. — The  prognosis  is  very  unfavorable.  Death  in  the 
fatal  cases  take  place  from  intercurrent  disease.  Patients  who  exhibit 
improvement  for  a  time  usually  succumb  later. 


LEUKEMIA  407 

Treatment. — The  management  is  entirely  supportive.  Iron  and 
arsenic  may  be  given  in  the  hope  that  they  will  be  of  some  benefit. 

LEUKEMIA 

Leukemia  is  a  disease  marked  by  the  cons  ant  presence  in  the  blood 
of  granular  mononuclears,  or  an  increase  in  the  blood  of  the  non-granu- 
lar cells  with  round  nuclei — the  miniature  cells  of  the  blood-building 
organs,  which  are  not  normally  present  in  the  peripheral  circulation. 
There  is  also  a  decided  change  in  the  blood  formula.  Generally  there  is 
a  marked  increase  in  the  leukocytes,  and  yet  there  are  instances  when 
the  count  is  normal  and  the  diagnosis  is  made  from  the  increase  of  ab- 
normal cells. 

Spleno myelogenous  Leukemia. — In  this  disease  there  is  a  great  in- 
crease in  the  granular  cells,  more  especially  the  myelocytes,  eosino- 
philes,  and  basophiles,  and  also  in  the  cells  with  spheric  or  slightly 
indented  nuclei  (Emerson).  The  total  blood  is  increased  in  the  ma- 
jority of  instances  and  diminished  in  few.  In  a  great  many  cases  the 
blood  may  appear  to  the  eye  normal;  in  extreme  cases  it  is  pale, 
opaque,  and  flows  sluggishly. 

The  red  cells  are  greatly  reduced  in  number — occasionally  as  low  as 
2,000,000.  Poikilocytosis  is  present  in  all  cases;  microcytosis  and 
macrocytosis  are  rare,  while  polychromatophilia  is  usually  present. 

This  is  the  condition  par  excellence  in  which  normoblasts  are 
present  in  abundance.  In  many  cases  megaloblasts  are  found.  The 
hemoglobin  is  much  reduced. 

The  white  cells  vary  from  100,000  to  500,000  (Holt),  or,  as  men- 
tioned before,  may  be  normal  in  number.  Neutrophiles  are  absolutely 
diminished,  but  relatively  increased.  The  lymphocytes  are  increased, 
but  vary  according  to  the  stage  of  the  disease.  Eosinophile  myelocytes 
are  found,  and  there  is  an  absolute  increase  in  the  eosinophiles.  Ehr- 
lich  states  that  in  this  disease  there  is  always  an  increase  in  the  baso- 
philes and  Cornil's  myelocytes  are  present. 

Lymphatic  Leukemia. — In  the  lymphatic  type  there  is  a  marked 
increase  in  the  mononuclears.  Despite  the  name,  the  increase  is  not 
always  in  the  lymphocytes,  although  this  increase  is  most  usually  in  the 
small  mononuclears,  which  in  some  cases  have  been  known  to  form 
97  per  cent,  of  the  total  white  cells.  Polymorphonuclears  are  rare. 
Eosinophile  cells  are  noticeably  absent,  and  in  a  pure  case  myelocytes 
are  not  present.  There  is  a  greater  anemia  in  this  form  than  in 
splenomyelogenous  leukemia. 

In  a  review  by  Churchill  (1904)  the  lowest  red-cell  count  reported 
was  750,000  after  a  severe  hemorrhage,  and  the  leukocytes  varied  from 
6000  to  810,000  (in  a  twenty-months'-old  child).  In  a  case  reported 
by  Wollstein  from  personal  observation  there  were  99  per  cent,  of 
small  mononuclears,  many  of  which  were  degenerated. 

Etiology  of  Leukemia. — Leukemia  is  rare  in  childhood.  Its  cause 
is  unknown. 


408  THE    PKACTICE    OF    PEDIATRICS 

Morbid  Anatomy. — The  bone-marrow  is  always  changed;  in  acute 
lymphatic  leukemia  it  is  red  or  gray,  with  an  increase  mostly  in  the 
lymphocytes.  In  myelogenous  leukemia  the  marrow  is  red,  grayish 
white,  or  greenish,  with  an  increase  in  the  myelocytes. 

The  spleen  is  enlarged  in  all  forms  of  leukemia,  and  may  be  enormous 
in  size. 

Adenoid  tissue  throughout  the  body  is  hyperplastic. 

The  liver  is  enlarged,  and  contains  many  small  grayish  or  yel- 
lowish areas  which  are  collections  of  leukocytes. 

The  lymph-nodes  are  always  enlarged  in  lymphatic  leukemia,  and 
may  be  enlarged  also  in  the  myelogenous  form.  The  cervical,  axillary, 
and  inguinal  nodes  may  form  masses  as  large  as  an  egg  or  even  larger. 
These  masses  are  soft,  painless,  and  not  adherent  to  the  skin. 

Leukemic  infiltrates  or  lymphomata,  circumscribed  or  diffuse,  con- 
sisting of  masses  of  lymphocytes,  may  be  present  in  the  kidneys, 
lungs,  skin,  peritoneum,  dura,  myocardium,  pancreas,  etc. 

Illustrative  Case. — A  boy,  four  years  of  age,  weighing  33  pounds,  was  referred  to 
me  by  Dr.  Brooke,  of  Bayonne,  N.  J.  For  nine  months  there  had  been  a  gradual 
abdominal  enlargement,  with  pallor  and  gradually  increasing  weakness ._  The 
spleen  was  enormously  enlarged,  extending  1  inch  above  the  pubes  and  IJ^  inches 
to  the  right  of  the  umbilicus.  Examination  of  the  blood  showed:  Hemoglobin,  35 
per  cent.;  red  blood-cells,  2,000,000;  white  blood-cells,  760,000;  myelocytes,  61 
per  cent.;  polynuclears,  41  per  cent.;  lymphocytes,  10  per  cent.  Benzol,  in  two 
minim  doses  (in  emulsion),  three  times  daily,  was  given  for  six  weeks,  at  which  time 
the  boy  showed  marked  improvement.  The  appetite  was  much  better.  He  was 
more  active.  The  general  appearance  was  decidedly  better.  The  spleen  had  ap- 
preciably decreased  in  size.  The  blood  examination  showed  that  the  general 
betterment  was  consistent:  Hemoglobin,  48  per  cent.;  red  blood-cells,  3,728,000; 
white  blood-cells,  272,000;  myelocytes,  27  per  cent.  After  three  months  the  child 
failed  rapidly  and  died  in  another  city  without  later  blood  examination. 

Prognosis. — The  prognosis  is  most  unfavorable.  Few  patients  sur- 
vive one  year  of  the  disease.  Reported  recoveries  probably  mean  er- 
rors in  diagnosis.     Death  usually  takes  place  from  intercurrent  disease. 

Treatment. — Nutritional  measures  should  be  brought  into  use. 
Iron,  arsenic,  and  cod-liver  oil  are  usually  employed.  Dr.  Frank 
Billings,  of  Chicago,  reports  benefit  in  five  adult  cases  treated  with 
benzol.  My  own  observation  with  benzol  has  been  as  unfavorable 
as  other  methods  of  treatment. 

PERNICIOUS    ANEMIA 

Pernicious  anemia  in  infants  and  young  children  is  very  rarely 
seen.  In  fact,  its  existence  in  children  has  been  questioned,  for  blood 
states  described  as  peculiar  to  pernicious  anemia  have  been  found  in 
other  diseases,  as  in  rachitis  and  syphilis,  in  which  there  is  extreme 
anemia.  On  the  other  hand,  cases  of  primary  pernicious  anemia 
have  been  reported  by  observers  of  repute  sufficiently  often  to  establish 
the  disease  as  an  entity. 

Lesions. — In  pernicious  anemia  there  is  extreme  general  pallor, 
and  fatty  degenerations  of  the  heart  muscle,  the  liver,  the  pancreas. 


PURPURA  409 

the  gastro-intestinal  epithelium,  and  the  kidneys.  In  addition, 
hemosiderosis  is  present  in  the  liver,  spleen,  bone-marrow,  and  kidneys 
due  to  the  destruction  of  red  blood-cells.  Capillary  hemorrhages 
into  the  viscera  are  rarely  lacking,  and  are  especially  frequent  in  the 
nervous  structures  and  in  the  serous  membranes.  The  color  of  the 
bone-marrow  may  be  changed  from  yellow  to  red,  and  microscop- 
ically shows  many  megaloblasts. 

The  Blood. — The  specific  gravity  and  coagulability  are  much  re- 
duced, and  the  hemoglobin  may  be  low  as  20  per  cent.  In  the  fresh 
specimen,  rouleaux  formation  is  absent,  and  the  cells  vary  much  in  size 
and  shape,  extreme  poikilocytosis  being  the  rule.  A  large  increase  in 
the  megalocytes,  with  absence  of  microcytes,  is  very  suggestive  of  the 
disease  in  question.  Owing  to  the  relatively  high  content  of  hemo- 
globin, the  red  cells  stain  fairly  well  and  uniformly,  but  in  many  cases 
there  is  a  degeneration  with  accumulation  of  hemoglobin  in  the  center 
of  the  cell.     The  megaloblasts  usually  outnumber  the  normoblasts. 

In  severe  and  uncomplicated  cases  there  is  always  a  leukopenia, 
and  the  polymorphonuclear  count  is  roughly  parallel  to  the  leukocyte 
count.     Myelocytes  are  usually  present. 

Symptoms. — The  symptoms  are  those  of  rapidly  progressive,  high- 
grade  anemia.  The  chief  symptoms  are  pallor  and  marked  exhaustion. 
The  patient  is  intensely  prostrated,  and  gastro-intestinal  crisis  de- 
velops. Emaciation  is  not  of  constant  occurrence.  Petechise  and 
submucous  hemorrhages  occur.  The  duration  of  the  disease  is  but 
a  few  months,  and  the  true  cases  are  fatal. 

PURPURA 

By  purpura  is  understood  a  condition  in  which  the  blood  either 
escapes  from  its  natural  channels  and  constitutes  a  hemorrhage,  or 
becomes  locahzed  in  different  portions  of  the  skin  and  subcutaneous 
tissue,  with  no  constant  change  in  its  character  or  demonstrable  lesion 
in  the  vascular  walls. 

Simple  Purpura. — Simple  purpura  occurs  in  the  form  of  petechise, 
often  as  a  terminal  symptom  in  exhausting  diseases.  It  may  result 
from  severe  vascular  strain,  as  in  pertussis.  I  have  seen  several  such 
cases.  Purpura  is  a  prominent  symptom  in  scorbutus  and  peliosis 
rheumatica.  It  may  occur  as  a  direct  effect  of  poisonous  drugs.  Thus 
in  my  own  cases  it  has  resulted  from  accidental  large  dosage  of  phos- 
phorus and  antipyrin.  In  a  vast  majority,  if  not  all,  of  the  cases, 
the  condition  is  due  to  toxic  agencies  originating  within  the  body  or 
introduced  from  without. 

The  Hemorrhagic  Type. — The  distinction  between  simple  and  hem- 
orrhagic purpura  is  largely  one  of  degree.  In  the  hemorrhagic  type 
there  are  free  hemorrhages  from  different  portions  of  the  body,  usually 
associated  with  extensive  subcutaneous  hemorrhage  or  hemorrhages 
into  different  organs.  Massive  hemorrhages  have  been  designated 
as  purpura  f ulminans,  or  Henoch 's  purpura,  and  here  again  the  differ- 


410  THE    PRACTICE    OF    PEDIATRICS 

entiation  is  based  upon  the  severity  of  the  condition  and  involves  an 
unnecessary  classification. 

The  hemorrhage  and  its  persistence  depend  upon  the  nature  of  the 
infection  and  the  resistance  of  the  individual. 

Illustrative  Cases. — One  of  my  patients,  two  years  of  age,  developed  a  mild 
purpura  while  taking  large  doses  of  antipyrin,  which  was  being  administered 
as  the  result  of  a  misunderstanding.  In  pyemia,  purpura  is  not  unusual.  In  a 
patient  nineteen  months  of  age,  who  died  from  a  septic  sinus  thrombosis  with 
extension  to  the  jugulars,  there  was  extensive  purpura  for  forty-eight  hours  before 
death.  Blood  examinations  made  from  this  patient  during  life  showed  pure  cul- 
tures of  streptococci.  Another  patient,  a  boy  eight  years  of  age,  previbusly 
healthy,  died  in  three  days  from  purpura  fulminans  (Henoch).  Death  resulted 
from  extensive  hemorrhages  under  the  skin,  combined  with  hemorrhages  from  the 
nose,  mouth,  and  intestines,  and  presumably  the  viscera.  An  autopsy  was  not 
allowed.  In  this  case  also  blood  cultures  made  postmortem,  from  subcutaneous 
hemorrhagic  areas,  showed  pure  growth  of  streptococci. 

A  notable  case  was  that  of  a  boy  seen  in  consultation  with  Dr.  Corwin,  of 
Rye,  N.  Y.  The  family  history  was  negative.  The  tonsils  and  adenoids  were 
removed  six  months  before  the  illness,  without  more  than  the  usual  bleeding. 
Two  months  before  the  illness  the  boy  fell  and  broke  off  an  incisor  tooth.  No 
bleeding  followed  the  accident.  On  June  15,  1910,  the  patient  was  taken  ill  with 
tonsillitis.  The  temperature  ranged  from  100°  to  102°F.,  and  continued  for  one 
week.  During  this  time  numerous  subcutaneous  hemorrhages  appeared  at  vari- 
ous sites  over  the  body,  particularly  on  the  leg.  A  large  hematoma  developed  in 
the  abdominal  wall.  There  was  some  bleeding  from  the  gums,  and  the  subcutane- 
ous hemorrhages  continued  to  appear  on  the  chest,  abdomen,  and  legs.  There 
was  moderate  bleeding  from  a  biscuspid  tooth.  The  child  was  given  calcium 
lactate  in  small  doses,  three  grains  every  three  hours.  The  hemorrhage  from  the 
gum  stopped,  and  the  subcutaneous  hemorrhages  began  to  show  signs  of  absorption. 

On  July  7th,  a  little  over  two  weeks  after  the  first  sign  of  the  purpura,  there  was 
a  hemorrhage  from  the  nose  which  lasted  about  an  hour.  On  the  following  day 
there  was  another  hemorrhage  from  the  nose  which  lasted  five  hours,  resisting  all 
ordinary  methods  of  control.  The  patient  was  at  this  time  seen  by  me.  He 
evidently  had  suffered  much  from  loss  of  blood.  The  eyes  were  sunken  and  the 
skin  was  pale  and  sallow  and  showed  in  many  areas  the  evidences  of  the  previous 
subcutaneous  hemorrhage.  The  child  was  markedly  prostrated.  Calcium  lactate 
was  resumed  in  10-grain  doses  every  two  hours.  On  account  of  the  greatly  reduced 
condition  of  the  patient,  normal  salt  solution  was  given  by  the  drop  method  through 
the  tube  introduced  into  the  colon.  The  stools  at  this  time  consisted  largely  of 
coagulated  blood. 

July  9th  the  hemorrhage  appeared  to  be  controlled.  Twenty  grains  of  calcium 
lactate  were  given  every  two  hours. 

July  10th  nasal  hemorrhage  began  at  5  a.  m.  and  continued  for  five  hours. 
Saline  irrigation  returned  blood-stained.  The  child  was  now  in  an  extreme  con- 
dition, and  30  c.c.  of  the  human  serum  were  injected  subcutaneously  by  Dr.  J.  E. 
Welch.  During  the  remainder  of  the  day  from  45  to  60  c.c.  of  the  human  blood- 
serum  were  injected  at  two-hour  intervals  until  midnight.  The  amount  injected 
in  twelve  hours  was  290  c.c.  In  the  evening  there  was  an  evacuation  of  the  bowels, 
composed  entirely  of  coagulated  blood. 

July  11th  the  stools  contained  blood,  and  the  expectoration  contained  some 
bright  red  blood.  There  was  a  moderate  nasal  hemorrhage.  At  8  a.  m.,  3  p.  m., 
and  9  p.  m.,  167  c.c.  of  human  blood-serum  were  given  in  three  doses. 

July  12th  there  was  no  visible  hemorrhage  from  any  portion  of  the  body. 
Four  injections  of  the  blood-serum  were  used,  the  total  amount  being  191  c.c. 

July  13th,  14th,  and  15th  three  injections  of  the  blood-serum  were  given  at 
about  six-hour  intervals,  in  quantities  ranging  from  20  to  30  c.c. 

July  16th  two  injections  of  the  serum  were  given,  at  twelve-hour  intervals, — 
44  c.c.  in  all, — and  on  July  17th  one  injection  of  35  c.c.  was  given.  The  total 
amount  of  serum  given  during  the  one  week  of  treatment  was  1034  c.c. 

From  this  time  the  child  manifested  a  slow  but  steady  improvement,  and  even- 
tually made  a  perfect  recovery.  It  was  of  interest  to  note  that  the  hemorrhage, 
which  had  continued  intermittently  for  nearly  three  weeks,  ceased  within  fifteen 
hours  after  the  first  injection  of  human  serum.     While  the  treatment  with  the 


HEMOPHILIA    (bleeder's    DISEASE)  411 

serum  was  being  carried  on  the  child  was  kept  alive  by  predigested  foods  and  free 
stimulation.  For  obvious  reasons,  a  blood  culture  was  not  made.  Without 
doubt  there  was  a  bacteremia  with  resulting  blood  changes  which  the  human  serum 
was  able  to  control. 

In  the  two  years  that  have  intervened  there  has  been  no  hemorrhage  nor  any 
suggestion  of  bleeding  from  any  portion  of  the  body. 

Apparently  here  was  a  case  in  which,  beyond  all  possibilities  of  doubt,  the  use  of 
the  human  blood-serum  saved  the  life  of  the  child. 

Prognosis. — The  prognosis  in  the  simple  cases  is  good.  The  phos- 
phorus-poisoning case  was  fatal,  but  not  alone  owing  to  the  hemor- 
rhage. In  hemorrhagic  cases  of  severe  type  the  outcome  appears  to 
depend  upon  the  promptness  with  which  human  serum  is  introduced 
into  the  circulation.  The  appearance  of  purpura  in  serious  or  pro- 
longed diseases  is  a  very  unfavorable  sign. 

Treatment. — The  treatment  of  the  milder  cases  is  that  of  the  dis- 
ease with  which  the  purpura  is  associated.  An  effort  should  be  made 
to  establish  the  vitality  and  resistance  of  the  patient  by  removal, 
when  possible,  of  the  cause  of  the  condition,  and  by  the  administra- 
tion of  acids  and  fruit-juices.  The  use  of  ergot  and  suprarenal  extract 
has  not  been  of  appreciable  service.  Calcium  lactate  has  appeared  to 
be  of  some  value  in  cases  not  severe.  Twenty  grains  should  be  given 
every  two  hours. 

Serum  Treatment. — As  a  means  of  prompt  relief,  human  blood- 
serum  far  exceeds  in  value  all  other  agents.  It  may  be  used  as  in- 
dicated in  the  case  referred  to.  From  2  to  4  ounces  should  be  given 
daily  until  the  hemorrhage  is  controlled.  (See  Hemorrhagic  Diseases 
of  the  Newly  Born,  p.  157.) 

HEMOPHILIA  (BLEEDER'S  DISEASE) 

By  ''hemophilia"  is  meant  a  constitutional  tendency  to  uncontroll- 
able bleeding,  spontaneous  or  arising  from  wounds  which  in  the  normal 
individual  occasion  little  or  no  bleeding  at  all. 

Etiology. — Isolated  cases  of  hemophilia  are  not  unknown  but  there 
is  no  doubt  that  the  family  histories  of  these  patients  are  defective. 
It  is  more  usually  the  case  that  the  bleeding  tendency  is  known  in  the 
family,  and  that  one  or  more  of  the  child 's  ancestors  has  suffered  from 
the  complaint,  or,  where  a  "bleeder"  has  been  born  of  healthy  parents 
that  one  or  more  of  the  succeeding  generations  is  affected. 

The  peculiarity  of  this  condition  lies  in  the  mode  of  inheritance; 
the  males  of  the  family  alone  are  affected,  while  the  tendency  is  trans- 
mitted through  the  females.  This  law  up  to  the  present  time  has  no 
authentic  exception  according  to  the  careful  researches  of  Bullock  and 
Fildes.  This  mode  of  inheritance  is  not  unique  for  there  is  evidence 
that  cases  of  partial  albinism  follow  the  same  law  (Nettleship)  and  it 
has  also  been  observed  in  certain  cases  of  color-blindness  and  night- 
blindness.  It  has  been  suggested  that  these  and  other  instances  are 
examples  which  can  be  best  explained  on  the  Mendelian  theory. 

In  a  family  of  bleeders,  the  female  members  transmit  the  disease 
and  the  males  manifest  it.     Thus,  a  girl  whose  mother  is  a  bleeder 


412  THE    PRACTICE    OF    PEDIATRICS 

will  not  show  signs  of  the  disease,  but  will  transmit  the  condition 
to  her  children  while  her  brother  will  be  a  bleeder  himself  and  yet  his 
children  by  a  healthy  wife,  will  not  be  bleeders,  although  his  grand- 
sons, through  his  daughters,  may  suffer  from  the  disease.  The  tend- 
ency to  transmit  hemophilia  is  no  stronger  in  a  woman  from  a  family 
of  bleeders,  who  herself  is  a  bleeder,  than  her  sister,  who  may  not  be  a 
bleeder.  Marriage  to  individuals  who  are  not  affected  is  no  means  of 
preventing  the  condition.  It  is  a  curious  fact  that  the  disease  has 
been  found  in  large  families. 

The  condition  is  rarely  noticed  at  birth  but  in  most  instances  is 
recognized  before  the  end  of  the  second  year  has  been  reached.  Before 
the  tenth  year  it  is  almost  always  fatal  and  after  the  twentieth  year  the 
condition  is  very  rare.  Most  of  the  cases  observed  have  been  among 
Germans  and  Jews,  while  it  is  practically  unknown  in  the  tropics. 

Pathology. — In  those  who  succumb  to  the  disease  the  chief  altera- 
tions are  due  to  the  draining  of  the  blood  from  the  organs.  With  this 
exception  there  is  no  constant  anatomical  change.  There  may  be  an 
endarteritis,  fatty  degeneration  of  the  intima  and  thinning  of  the 
vessel  walls  making  the  arteries  resemble  the  veins. 

Blood  Changes. — There  is  usually  a  slight  decrease  in  the  number 
of  leukocytes  especially  of  the  polymorphonuclear  variety  and  beyond 
this  the  changes  are  but  transitory.  Following  a  severe  hemorrhage 
the  red  cells  are  promptly  restored  to  their  normal  number,  and  the 
hemoglobin  much  more  slowly,  so  that  a  simple  anemia  may  be  present 
for  weeks  following  a  severe  hemorrhage. 

The  various  observations  recorded  regarding  the  coagulation  time 
are  most  conflicting  and  are  probably  due  to  the  lack  of  uniformity 
of  technique.  Wright  believes  that  the  coagulation  is  much  prolonged 
while  Sahli  considers  it  diminished  in  the  interval  and  normal  or 
increased  during  the  height  of  an  attack. 

Various  hypotheses  have  been  propounded  to  explain  this  abnor- 
mal tendency  to  hemorrhage  such  as  abnormal  fragihty  of  the  vessel 
walls  (Virchow)  increased  blood- pressure  (Immerman)  a  definite  in- 
fectious process  (Koch)  while  Sahli  considers  it  an  abnormal  chemical 
alteration  in  the  walls  of  the  blood-vessels,  which  results  in  the  failure 
of  a  substance  (thrombokinase)  which  is  essential  to  the  formation 
of  a  clot. 

Symptoms. — The  first  manifestations  of  hemophilia  are  not  often 
seen  before  the  second  year.  The  hemorrhages  of  the  newly  born 
have  no  relation  to  this  condition.  The  most  significant  symptom  is 
bleeding  of  a  serious  nature  from  slight  injury  or  no  apparent  cause. 
There  may  be  a  severe  sudden  hemorrhage,  or  a  constant  oozing  of 
blood  which  resists  all  attempts  to  check  it.  Such  trivial  injuries  as 
the  extraction  of  a  tooth  or  even  dentition,  may  give  rise  to  prolonged 
bleeding  of  a  serious  aspect  but  it  is  a  curious  fact  that  menstruation 
and  childbirth,  are  not,  as  a  rule  accompanied  by  great  loss  of  blood. 
These  hemorrhages,  usually  of  mucous  membranes,  take  place  in  the 
gums,  nose,  throat  or  bowel.     Effusion  of  blood  into  the  joints  may  be 


hodgkin's  disease  (lymphadenoma)  413 

chronic  with  some  hmitation  of  motion  and  even  ankylosis  resulting. 
Following  these  hemorrhages  we  have  symptoms  common  to  hemor- 
rhage from  any  cause  and  if  it  be  a  fatal  one  the  patient  dies  from 
exhaustion.  Sometimes  death  is  preceded  by,  or  occurs,  during  a 
convulsion. 

Prognosis. — The  prognosis  is  on  the  whole  bad  in  childhood. 
Fully  half  of  the  hemophilic  patients  die  before  reaching  their  eighth 
year  and  less  than  12  per  cent,  survive  to  puberty  (Littar  v.  Et- 
linger).    The  first  manifestation  rarely  kills. 

Diagnosis. — The  diagnosis  of  hemophilia  must  rest  to  a  large 
extent  upon  a  knowledge  of  the  family  history.  Where  there  is  no 
known  "bleeder"  in  the  pedigree,  the  diagnosis  of  hemophilia  is  always 
open  to  criticism.  It  must  be  remembered  that  there  are  other  causes 
of  repeated  and  obstinate  hemorrhage  than  hemophilia,  that,  for  in- 
stance, in  recurrent  idiopathic  purpura,  such  hemorrhages  are  met  with, 
and  that  effusion  into  the  joint  cavities  occur  in  both  diseases.  In 
hemophilia  the  effusion  is  bloody;  in  purpura  it  is  invariably  serous. 
In  hemophilia  according  to  Pratt  there  are  about  450,000  platelets 
per  cubic  centimeter  whereas  in  purpura  there  are  50,000  or  less. 
Blood  examination  rules  out  anemias  and  leukemias. 

Treatment. — Prophylaxis  is  the  most  effective  treatment,  marriage 
should  be  discountenanced.  Such  advice,  however,  is  rarely  followed 
out  as  the  records  of  the  various  "bleeder"  families  show.  The 
patient  should  be  guarded  from  birth  against  all  operations  unless  they 
be  of  a  life-saving  nature  and  then  previous  treatment  with  calcium 
lactate  or  thyroid  should  be  used,  while  at  the  time  of  operation  blood 
serum  may  be  injected  subcutaneously. 

In  the  event  of  hemorrhage  styptics  should  be  employed,  the  most 
effective  being  tannic  acid  or  the  perchloride  of  iron.  Good  results 
are  obtained  from  the  administration  of  calcium  lactate  in  the  dose 
of  15  grains  three  times  daily  in  cases  of  persistent  epistaxis.  Gelatine 
is  of  little  service.  In  cases  of  severe  hemorrhage  blood  transfusion 
should  be  resorted  to  and  if  practicable  the  father's  blood  should  be 
employed.  Numerous  cases  are  on  record  where  this  procedure  has 
tided  patients  over  critical  periods.  If  transfusion  is  impossible  re- 
peated injections  of  human  serum  or  even  animal  serum  may  be 
employed. 

HODGKIN'S  DISEASE  (LYMPHADENOMA) 

The  best  description  of  this  disease  coming  to  my  observation  is  to 
be  found  in  the  Johns  Hopkins  Hospital  Reports,  vol.  x,  by  Dr.  Reed. 

Hodgkin's  disease  is  of  extreme  rarity  in  children.  The  onset  is 
very  gradual.  The  first  symptoms  are  usually  those  of  an  enlargement 
of  the  glands  of  the  neck — usually  a  one-sided  involvement.  There 
is  an  associated  anemia,  progressive  in  type.  On  account  of  the  en- 
largement of  the  glands,  there  may  be  pressure,  pain,  cough,  and  ob- 
struction to  respiration.  The  glandular  enlargement  may  become  ex- 
treme.    The  only  changes  in  the  blood  are  those  of  marked  anemia. 


414  THE    PRACTICE    OF    PEDIATRICS 

Lesions. — The  lymph-nodes  are  enlarged.  At  first  they  are  soft, 
gray  or  grayish  red,  moist,  and  show  irregular  areas  of  necrosis, 
which  are  very  characteristic.  Microscopically,  eosinophiles,  giant- 
cells,  and  some  plasma  cells  are  seen.  Later  the  glands  become  small 
and  hard,  showing,  on  section,  a  glistening,  white  cut  surface.  This  is 
the  stage  of  cicatrization  (Aschoff) . 

The  spleen  is  enlarged,  but  not  so  markedly  as  in  leukemia.  The 
cut  surface  is  mottled  and  irregular,  due  to  red  or  gray  masses  (lym- 
phomata)  in  the  follicles. 

There  may  be  enlargement  of  all  the  adenoid  tissue  in  the  body, 
and  lymphomata,  smaller  than  those  found  in  leukemia,  may  be  present 
in  the  liver,  lungs,  kidneys. 

Treatment. — All  the  means  used  have  been  ineffectual  in  true  cases. 


XL  THE  GLANDULAR  SYSTEM 

DISEASES  OF  THE  LYMPHATIC  GLANDS 

Lymphatic  gland  enlargement  is  of  most  frequent  occurrence  in 
children.  It  is  quite  usual,  in  making  a  physical  examination  in 
children,  to  find  the  postcervical  and  the  inguinal  glands  slightly 
enlarged.     Such  enlargement  is  frequently  of  no  significance. 

ACUTE     CERVICAL  ADENITIS 

Infants  and  young  children  possess  a  ready  susceptibility  to  gland 
infection.  There  may  be  a  general  glandular  involvement — in  such 
instances  the  child  may  be  in  depleted  condition  and  the  glandular 
hyperplasia  is  of  no  consequence.  In  these  cases,  the  glands  will 
show  but  very  slight  or  moderate  enlargement.  In  pseudo-leukemia, 
leukemia  and  lymphatism  the  glands  will  show  a  vastly  greater  degree 
of  hyperplasia,  and  the  blood  examination  will  determine  this  condition. 
In  syphilis  the  only  glandular  involvement  of  signifiance  will  be  found 
in  the  epitrochlears. 

In  tuberculosis  the  process  is  always  localized,  usually  at  the  angle 
of  the  jaw.  The  inguinal  glands  are  often  found  enlarged  in  eczema, 
intertrigo  and  in  balanitis.  Pediculi  of  the  scalp  are  very  apt  to 
produce  involvement  of  the  posterior  cervical  glands. 

Etiology. — In  cervical  adenitis  the  inflammation  results  from  the 
draining  of  an  infected  source,  which  may  be  a  decayed  tooth,  a  diseased 
tonsil,  a  purulent  rhinitis,  or  any  focus  from  which  bacteria  may  be 
transferred.  In  grip,  tonsillitis,  scarlet  fever,  diphtheria,  measles,  and 
in  any  throat  infection,  adenitis  may  be  and  frequently  is  a  complication. 

Pathology. — The  process  in  the  gland  may  be  a  simple  hyperplastic 
change,  or  it  may  reach  the  stage  of  suppuration.  The  microorganism 
most  commonly  associated  with  suppurative  adenitis  is  the  strepto- 
coccus, but  the  staphylococcus,  the  pneumococcus,  the  gonococcus, 
and  the  typhoid  bacillus  have  been  cultivated  from  diseased  lymph- 
glands  in  various  regions. 

Symptoms. — The  first  symptom  noticed  will  be  that  of  a  swelling 
at  the  angle  of  the  jaw  (Fig.  48),  hard,  rounded,  and  quite  painful  to 
the  touch.  Preceding  the  enlargement  there  may  be  a  period  of  fever 
for  a  day  or  two,  during  which  time  the  child  moves  the  head  awk- 
wardly. Rarely  one  gland  alone  will  be  involved.  Usually  there  are 
several,  although  the  external  examinations  will  make  it  appear  that 
one,  or  at  the  most,  two,  are  enlarged.  The  tumor  may  reach  a  very 
large  size.  I  have  seen  the  entire  space  between  the  jaw  and  the  clav- 
icle filled  in  and  almost  replaced  by  these  glands. 

415 


416 


THE    PRACTICE    OF    PEDIATRICS 


The  temperature  is  usually  high.  In  simple  adenitis  with  suppura- 
tion I  have  repeatedly  seen  it  range  from  102°  to  105°F. 

Duration. — The  duration  varies  widely.  If  there  is  a  streptococcus 
infection,  suppuration  may  occur  in  a  few  days.  In  scarlet  fever  this 
microorganism  is  usually  the  infecting  agent,  a  fact  which  accounts  for 
the  many  suppurating  glands  that  occur  with  this  disease. 

Termination, — The  infection  always  terminates  in  one  of  three 
ways:  First,  resolution;  second,  suppuration;  third,  persistent  enlarge- 
ment (chronic  adenitis). 


Fig.  48. — Cervical  adenitis. 


Differential  Diagnosis. — Acute  adenitis  and  mumps  are  very  fre- 
quently confused.  By  a  comparison  of  Fig.  48  and  Fig.  84  it  will  be 
readily  seen  that  the  two  conditions  have  but  little  in  common.  In 
mumps  the  parotid  gland  is  involved  and  the  swelling  is  situated  close 
to  the  ear,  with  the  space  posterior  to  the  lobe  filled  in  by  that  portion 
of  the  parotid  gland. 

Prophylaxis. — A  normal,  resistant  throat  is  the  best  safeguard 
against  cervical  adenitis.     Removal  of  adenoids  and  enucleation  of  the 


ACUTE    CERVICAL    ADENITIS 


417 


tonsils  are  better  insurance  against  cervical  gland  infection  than  all 

other  means  combined. 

Axillary  and  Inguinal  Adenitis. — In  axillary  and  inguinal  adenitis 

the  infected  area  from  which  the  process  has  its  origin  must  be  eradi- 
cated.    In  the  inguinal  cases  balanitis  in  boys  and  vulvovaginitis  in 

girls  are  frequent  sources  of  infection.     Axillary  adenitis  (Fig.  49)  is 

very  unusual.     When  it  occurs,  the  infection  has  usually  been  carried 

ifrom  a  lesion  somewhere  in  the  upper  extremity. 

Treatment. — After  treating  many  hundreds  of  cases  of  adenitis,  I 

have  been  impressed  with  the  great  value  of  cold  applications  in  the  form 

of  a  cold-water  compress  changed  every  fifteen  minutes  to  half-hour, 

day  and  night.      Such 

treatment    is   arduous, 

and,  of  course,  in  many 

instances      impossible, 

particularly  in  dealing 

with     young     infants. 

With     older     children 

the    dressing    may    be 

changed      withou 

awakening  the  patient 

For  infants  the  treat 

ment  may  be  con 
tinued  with  good  effect 
from  14  to  16  times  a 
day.  The  last  dressing 
for  the  night  is  to  be 
kept  bound  on  the 
parts.  The  use  of 
ointments  and  local 
applications  other  than 
cold  is  disappointing. 
The  ice-bag  is  not  so 
satisfactory  as  the  wet 
compress. 

Suppurative  Cases. — Even  when  the  cold  compress  or  ice-bag  is 
applied  at  the  first  suggestion  of  swelling  and  used  faithfully,  the  cases 
of  streptococcus  infection  usually  go  on  to  suppuration.  Repeatedly 
I  have  seen  the  adenitis,  which  is  often  an  early  complication  of  diph- 
theria, disappear  quickly  after  full  doses  of  diphtheria  antitoxin.  When 
the  swelling  softens,  we  know  that  suppuration  has  taken  place,  and  our 
only  treatment  is  to  incise  freely,  allowing  the  pus  to  escape,  and  place 
in  the  wound  a  strip  of  sterilized  gauze  to  assist  in  drainage  and  to  pre- 
vent too  early  closure  of  the  incision.  The  wound  should  be  dressed 
once  daily.  Extirpation  of  the  diseased  gland  is  not  to  be  advised  until 
later,  if  at  all.  In  fact,  a  greater  part  of  all  the  gland  tissue  may  have 
undergone  suppuration,  producing  complete  destruction. 
27 


Fig.  49. — Axillary  adenitis. 


418 


THE    PRACTICE    OF    PEDIATRICS 


PERSISTENT  SIMPLE  ADENITIS 
After  an  acute  adenitis,  in  a  small  percentage  of  cases,  the  gland  or 
glands  will  remain  persistently  enlarged,  so  as  to  constitute  a  deformity. 
The  deformity  may  likewise  be  the  result  of  a  series  of  acute  attacks, 
each  leaving  the  gland  a  little  larger  than  before.  Whether  these 
glands  are  tuberculous  from  the  outset,  or  become  so  later,  it  is  im- 
possible to  state.  I  know,  however,  from  observation  of  many  patients, 
that  some,  cases  which  do  not  show  the  distinctive  characteristics  of 
tuberculous  adenitis  which  we  have  been  taught  to  expect,  do  show 
that  they  are  tuberculous  upon  examination  of  the  glands  which  have 

been  removed  at  operation 
because  of  the  unsightly 
deformity.  I  have,  there- 
fore, come  to  look  upon 
pronounced  persistent 
adenitis  as  probably  of 
tuberculous  origin,  even 
though  but  two  or  three 
glands  appear  to  be  in- 
volved. Because  these 
chronically  enlarged  glands 
sometimes  undergo  resolu- 
tion without  suppuration 
does  not  prove  the  absence 
of  tubercle  bacilli. 

Treatment. — I  have 
treated  these  cases  of  per- 
sistent adenitis  with  elec- 
tricity, drugs,  and  local 
medicinal  applications,  but 
am  unable  to  advise  the 
use  of  any  one  of  them,  nor 
have  the  iodids  in  my  hands 
been  of  any  appreciable  value.  The  only  local  means  of  utility  has 
been  the  more  or  less  persistent  applications  of  cold  in  the  form  of  a 
wet  compress.  The  dressing  is  changed  every  half-hour — a  treatment 
which  is  never  popular,  but  which  sometimes  succeeds.  At  bedtime 
the  tumor  is  massaged  for  fifteen  minutes  with  any  non-irritating  oil. 
The  Bier  Hyperemia  Treatment  (Fig.  50). — This  method  of  treat- 
ment consists  in  the  application  of  the  Bier  neck  band  (Kny-Scheerer, 
New  York)  sufficiently  tight  to  produce  a  slight  capillary  engorgement 
of  the  skin  over  the  face.  The  band  is  worn  for  eleven  hours,  and  kept 
off  one  hour.  This  method  of  treatment  is  of  some  value  in  the  more 
acute  cases,  in  which  the  glandular  involvement  has  resisted  cold 
appHcation  and  promises  to  pass  into  the  chronic  stage. 

Constitutional  means,  of  course,  should  be  employed,  iron,  cod- 
hver  oil,  and  the  hypophosphites  being  prescribed,  if  the  child's 
condition  appears  to  require  them.     In  many  cases,  however,  such 


Fig.  50. — Cervical  adenitis,  showing  Bier  band 
in  position  (five  and  one-half  months). 


GLANDULAR    FEVER  419 

treatment  is  not  called  for,  as  the  children  are  in  perfect  condition,  the 
process  being  entirely  local.  I  have  had  no  experience  with  the  ' '  a;-ray ' ' 
and  various  "light"  methods  of  treatment  which  are  advocated  by 
some  writers.  My  own  observation  in  the  management  of  these  cases 
has  been  that  when  the  glands  remain  for  several  weeks  sufficiently 
large  to  produce  a  deformity,  removal  by  surgical  means  is  the  only 
course  to  pursue.  The  operation  is  simple  in  good  hands,  is  quickly 
performed,  and  need  leave  but  a  very  slight  scar. 

GLANDULAR  FEVER 

Glandular  fever  is  a  disease  of  early  childhood.  It  is  rarely  seen 
in  children  after  the  fifth  year.  It  is  characterized  by  swelling  of  the 
lymph-nodes  at  the  angle  of  the  jaw  forming  an  elongated  tumor  be- 
tween the  angle  of  the  jaw  and  the  sterno-mastoid  muscle.  The  tumor 
may  reach  a  considerable  size.  I  have  seen  cases  in  which  the  tumors 
were  as  large  as  hen 's  eggs.  Both  sides  are  usually  involved;  the  swell- 
ing is  first  noticed  on  one  side  and  is  usually  followed  by  an  infection 
of  the  glands  on  the  opposite  side.  Rarely  are  the  axillary  and  in- 
guinal glands  affected.  Fever  is  present,  usually  from  101°  to  104°F., 
there  is  prostration  and  loss  of  appetite. 

The  disease  occurs  most  frequently  in  epidemic  form  although 
sporadic  cases  are  not  unusual.  Park  West*  described  an  epidemic  of 
96  cases  in  43  families  during  a  period  of  three  years.  The  last  large 
epidemic  was  described  by  Schaffer  in  1909.  A  similar  outbreak  oc- 
curred in  New  York  City  in  the  Spring  of  1911.  During  this  epidemic 
I  treated  30  cases  in  my  own  private  practice. 

Pathology  and  Bacteriology. — The  pathology  of  this  affection 
is  obscure.  So  far  the  evidence  at  hand  tends  to  point  to  a  streptococcus 
infection  and  with  the  improved  technique  of  blood  cultures  in  infants, 
an  answer  to  this  question  should  be  forthcoming  in  the  near  future. 
Cultures  from  the  throat  have  shown  no  uniform  results  but  in  many 
instances  streptococci  have  been  found  in  the  pus  either  at  autopsy 
or  operation.  Korsakoff  found  streptococci  in  pure  culture  in  the 
cervical  and  axillary  glands,  liver,  spleen,  kidneys  and  heart's  blood, 
while  in  the  same  case  the  glands  showed  an  acute  hyperplastic  change 
with  dilated  blood-vessels.  In  reports  of  cases,  blood  cultures  during 
life  are  not  mentioned. 

Differential  Diagnosis. — This  disease  is  to  be  differentiated  from 
mumps  in  that  the  parotid  glands  are  not  involved,  and  from  acute 
simple  adenitis  by  the  absence  of  throat  involvement  and  by  the  fact 
that  nearly  all  cases  recover  without  suppuration  or  resulting  per- 
sistent adenitis.  In  several  of  the  cases  seen  during  a  recent  epidemic 
the  rhino-pharynx  was  normal.  Two  or  more  children  in  a  family 
may  have  the  disease  at  the  same  time. 

Treatment. — The  treatment  consists  in  the  continuous  use  of 
ice-bags  or  the  cold  compress  (p.  283)  and  laxatives  such  as  milk 
*  Arch,  of  Pediatrics,  1896. 


420  THE    PRACTICE    OF    PEDIATRICS 

of  magnesia,  sufficient  to  produce  one  or  two  evacuations  daily,  a 
reduced  diet  of  broths  and  gruels,  and  keeping  the  patient  in  bed. 
The  swelling  may  last  from  five  days  to  two  weeks,  and  in  my  cases  has 
subsided  without  suppuration. 

TUBERCULOUS   ADENITIS 

Tuberculous  adenitis  is  a  term  applied  by  common  consent  to 
tuberculosis  of  the  cervical  lymph-nodes.  In  cases  of  early  and  local- 
ized tuberculous  involvement,  these  glands,  more  often  than  any  other 
structures,  harbor  the  bacilli.  Furthermore,  because  of  the  possibility 
of  ready  access  to  the  source  of  the  disease,  these  cases  present  a 
better  prognosis  as  regards  its  eradication  than  do  cases  of  tuberculosis 
in  any  other  part  of  the  body. 

Age. — The  age  incidence  is  interesting.  Cases  are  rarely  seen  before 
the  third  year  and  do  not  often  develop  after  the  eighth  year.  I  have 
known  cases,  however,  to  develop  much  later.  My  oldest  patient  was 
a  girl  sixteen  years  of  age  who  was  otherwise  healthy. 

Conditions  Favoring  the  Development  of  Lymph -node  Tuberculosis. 
— Diseased  tonsils  and  adenoids  are  the  most  fruitful  cause  of  tubercu- 
lous cervical  lymph-glands. 

Whether  previous  inflammatory  condition  of  the  glands  makes 
them  a  more  favorable  host  is  not  known ;  neither  do  we  know  when  the 
glands  become  tuberculous.  Is  the  tubercle  bacillus  the  first  offender? 
Holt  believes  that  in  most  cases  tuberculosis  is  the  primary  infec- 
tion. Heredity  probably  plays  no  part  in  causation.  That  lympha- 
tism  may  predispose  an  individual  to  the  infection  is  extremely  doubt- 
ful. It  has  not  been  my  observation  that  children  predisposed  to 
glandular  enlargement  from  some  systemic  cause  are  especially  sus- 
ceptible to  bacterial  infection.  It  is  my  belief  that  tuberculous  glands 
are  dependent  for  the  infection  upon  the  presence  of  tubercle  bacilli  in 
the  food  and  air,  and  upon  a  means  of  communication  to  the  gland 
which  is  perfectly  supplied  by  those  lymphatics  whose  function  it  is 
to  drain  bacteria-laden  tonsils  and  adenoids. 

Contributory  to  this  belief  is  the  fact  that  the  age  from  the  third 
to  the  eighth  year  is  the  period  during  which  diseased  tonsils  and 
adenoids  are  of  the  most  frequent  occurrence. 

Types  of  Infection. — In  the  majority  of  cases  of  primary  cervical 
adenitis  in  children  the  tubercle  bacilli,  which  have  been  isolated  by 
observers  in  this  country,  England,  and  Germany,  have  conformed  to  the 
human  type.  From  bronchial  and  mesenteric  lymph-nodes  affected 
with  tuberculosis  in  young  children  Gofflsey  isolated  the  human 
type  in  55  out  of  57  cases.  In  two  the  bovine  strains  were  present  in 
the  bronchial  nodes.  Tuberculous  glands  which  have  undergone 
suppuration  are  usually  the  seat  of  a  secondary  infection  with  the 
streptococcus. 

Symptoms. — A  symptomatology  of  value  in  tuberculous  adenitis  is 
most  difficult,  as  we  do  not  know  positively  when  a  gland  becomes  in- 


TUBERCULOUS    ADENITIS 


421 


fected.  Knowledge  of  very  early  symptoms  is  therefore  out  of  the 
question.  Cervical  glands  are  prone  to  enlargement.  One  or  more 
may  enlarge  and  disappear  or  diminish  in  size,  and  enlarge  again  and 
disappear  and  never  trouble  the  child  thereafter.  In  another  case  per- 
haps the  same  phenomenon  occurs,  but  the  glands  do  not  diminish  in 
size  or  disappear  as  formerly,  but,  on  the  contrary,  remain  enlarged. 
In  well-developed  adenitis  the  glands  cease  to  be  movable.  A  peri- 
adenitis binds  them  to  the  skin  and  the  adjacent  tissue  and  probably 
to  the  adjacent  glands. 
The  involved  glands  may 
be  small  or  large.  I  have 
repeatedly  seen  tuber- 
culous glands  as  small 
as  a  pea  undergoing 
typical  cheesy  degenera- 
tion. Usually  one  side 
of  the  neck  is  involved. 
Secondary  infection  is 
productive  of  abscess; 
the  skin  over  the  super- 
ficially seated  gland  be- 
comes acutely  reddened 
and  breaks  down  if  not 
opened,  discharging  thin, 
light-yellow  pus.  Other 
glands  undergo  the  same 
process  of  infection,  fol- 
lowed by  cheesy  degen- 
eration and  suppuration, 
with  the  formation  of  a 
sinus  and  destruction  of 
skin.  Attempts  at  reso- 
lution produce  cicatricial 
changes  which  add  to 
the  unsightliness  of  the 

wound.     The  entire  process  is  a  chronic  one,  and  requires  years  to 
produce  the  clinical  picture  represented  in  Fig.  51. 

Prognosis. — The  prognosis  is  the  same  as  in  so  many  diseases  in 
which  the  treatment  is  surgical.  The  outlook  is  most  satisfactory  if 
the  surgeon  is  given  an  opportunity  to  operate  early.  The  girl  of 
sixteen  years  previously  referred  to  was  undergoing  treatment  for 
tuberculous  nodes  by  means  other  than  operation.  After  three  months 
of  treatment  she  developed  tuberculous  meningitis.  This  incident 
occurred  very  early  in  my  medical  career. 

Treatment. — My  present  position  is  as  follows :  If  the  gland  may  be 
diagnosed  as  tuberculous,  surgical  procedures  should  be  brought  into 
the  case.  If  the  diagnosis  is  not  positive,  but  the  gland  or  glands 
remain  persistently  enlarged  to  a  degree  sufficient  to  produce  a  de- 


Fig.  51. — Cicatrices  following  a  neglected  case 
of  tuberculous  adenitis  in  a  girl  seven  years  old. 
There  is  also  a  tuberculous  patch  upon  the  skin  of 
the  cheek  in  a  very  frequent  location  (Holt). 


422  THE    PRACTICE    OF    PEDIATRICS 

formity,  the  case  should  be  placed  in  the  suspected  class  and  opera- 
tion should  be  performed. 

The  operation  is  usually  attended  with  most  satisfactory  results, 
but  should  be  attempted  only  by  a  competent  surgeon.  I  have  known 
results  that  were  not  satisfactory.  The  possibilities  of  an  unsightly 
scar  deter  many  parents  from  assenting  to  an  operation.  If  the  opera- 
tion is  performed  by  the  Dowd  method*  before  ulceration  of  the  skin 
develops,  the  scar  is  negligible.  Long  before  adult  life  is  reached  it 
will  not  be  visible. 

After  the  operation  the  child  should,  if  possible,  be  given  the  ad- 
vantage of  an  outdoor  life  in  the  country,  inland.  These  cases  appear 
to  improve  most  rapidly  at  an  elevation  of  800  feet  or  more.  The  diet 
should  consist  of  meat,  eggs,  milk,  and  of  high-proteid  cereals,  such  as 
oatmeal  and  the  dried  legumes,  given  in  the  form  of  purees.  It  is  my 
custom  to  order  cod-liver  oil  and  malt  to  be  given  in  doses  of  from 
one  teaspoonful  to  one  tablespoonful  after  meals  for  one  week, 
followed  for  one  week  by  the  syrup  of  the  hypophosphites.  The  oil 
and  malt  may  then  be  resumed  for  the  same  time,  thus  alternating  in- 
definitely with  the  hypophosphites.  If  an  examination  of  the  blood 
shows  that  the  patient  is  anemic,  iron  may  be  used  in  connection  with 
the  other  remedies.  The  citrate  of  iron  and  extractum  ferri  pomatum 
are  well  borne  by  the  stomach,  and  have  appeared  to  be  of  considerable 
service  in  some  of  my  cases.  To  children  from  five  to  ten  years  of 
age  one  grain  of  the  citrate  of  iron  and  quinin  in  sherry  wine,  or  one 
grain  of  citrate  of  iron  and  ammonia  in  water,  may  be  given  after 
meals.  The  dose  of  extractum  ferri  pomatum  at  this  age  is  one-half 
grain  after  each  meal. 

MASTITIS  IN  YOUNG  GIRLS 

Inflammation  of  the  mammary  gland  in  young  girls  is  a  compara- 
tively rare  condition,  but  one  of  sufficiently  frequent  occurrence  to  re- 
quire mention.  Swelling  and  tenderness  of  the  breasts,  although  often 
complained  of  by  young  girls  about  the  time  of  puberty,  subside 
without  treatment  if  let  alone.  My  cases  of  true  mastitis  have  varied 
in  age  from  seven  to  twelve  years.  The  condition  is  usually  due  to  the 
entrance  of  bacteria  through  the  nipple,  and  in  its  clinical  manifesta- 
tions it  resembles  mastitis  in  the  adult,  except  that  the  entire  gland 
is  usually  involved,  becoming  swollen,  tender,  and  excruciatingly  pain- 
ful. There  is  slight  fever, — not  above  101°F., — headache,  and 
lassitude. 

Treatment. — Satisfactory  treatment  during  the  acute  stage  has 
consisted  in  the  use  of  an  ice-bag,  which  is  kept  constantly  applied 
during  the  waking  hours.  At  night  a  wet  dressing  of  bichlorid  of 
mercury,  1 :  5000,  should  be  kept  on  the  infected  glands.  A  saline  laxa- 
tive in  the  form  of  citrate  of  magnesia  should  be  given  at  the  onset, 

*  Surgery,  Gyn.  &  Obs.,  vol.  viii,  pp.  232-237,  Mar.,  1909,  and  Journ.  A.  M.  A., 
vol.  Ixvii,  pp.  499-503,  Aug.,  1916. 


THE    THYMUS    GLAND  423 

and  a  diet  of  broth,  gruel,  toast,  and  stewed  fruit  is  to  be  continued 
during  the  period  of  fever.  Recovery  is  usual  under  two  weeks.  The 
ice-bag  has  not  been  required  for  more  than  three  or  four  days.  After 
this  period  the  wet  dressing  answers  the  same  purpose. 

THE  THYMUS  GLAND 

The  thymus  consists  of  two  lobes,  faintly  red  in  color.  They  are 
more  or  less  pointed  toward  the  upper  part,  rounded  off  toward  the 
lower,  and  bound  together  with  loose  connective  tissue.  The  organ  is 
situated  in  the  anterior  mediastinum,  and  the  greater  portion  of  the 
gland  lies  behind  the  manubrium  and  body  of  the  sternum.  Sappey 
has  demonstrated  that  the  thymus  in  the  new-born  infant  reaches  from 
the  upper  edge  of  the  manubrium  5  cm.  downward,  while  the  upper 
border  at  times  may  reach  the  isthmus  of  the  thyroid,  or  be  2  to  3  cm. 
below  it.  The  sides  and  lower  portion  are  covered  by  the  folds  of  the 
mediastinum,  while  the  anterior  borders  of  the  lungs  and  loose  connec- 
tive tissue  separate  the  gland  from  the  chest-wall.  Posteriorly,  the 
gland  covers  the  pericardium  in  its  upper  two-thirds,  and  the  beginning 
of  the  great  vessels.  Its  elongated  upper  edges  cover  the  trachea.  The 
vagi  and  phrenic  nerves  and  common  carotid  arteries  bound  it  on 
either  side,  while  posteriorly,  again  in  close  relation,  are  the  phrenic 
nerves.  The  average  width  is  2  to  3  cm.,  and  at  times  the  longitudinal 
diameter  may  reach  113-^  cm. 

"Weight  and  Size. — As  found  postmortem,  the  size  and  weight  of 
this  gland-like  organ  vary  considerably,  and,  at  the  present  time,  there 
is  a  wide  variation  of  opinion  respecting  the  normal.  Probably  the 
most  exhaustive  work  on  this  point  was  done  by  Bovaird  and  NicoU, 
who  weighed  the  thymus  in  495  consecutive  autopsies,  the  results  of 
which  were  published  in  1906.  They  found  the  greatest  weight  at 
birth,  the  average  being  7.7  gm.  Following  this  there  was  little  change 
until  the  period  of  five  years  was  reached,  from  which  time  a  gradual 
reduction  took  place.  Judging  from  these  observations,  one  may  con- 
clude that  the  average  weight  at  birth  is  6  to  7  gm. ;  from  birth  to  five 
years,  3  to  4  gm. ;  and  that  any  weight  over  10  gm.  may  be  considered 
abnormal. 

Olivier,  in  his  extensive  monograph,  gives  the  following  figures: 

Birth 4  gin. 

1  year 6    " 

2  vears 8    " 

3  " 10    " 

He  considers  all  thymi  over  15  gm.  to  be  hypertrophied.  Sappey, 
Murkel,  and  Testut  all  quote  figures  higher  than  Olivier.  Friedleben 
and  other  observers  pointed  out,  some  time  ago,  that  these  variations 
in  the  weight  and  size  of  the  thymus  may  be  accounted  for  by  the  body 
nutrition.  It  appears  that  the  thymus  shows  the  results  of  excessive 
loss  much  more  than  the  body  as  a  whole,  for  in  exhausting  diseases 
the  weight  of  the  thymus  sinks  much  more  rapidly  than  that  of  the 


424  THE  PRACTICE  OF  PEDIATRICS 

body.  In  exceptional  cases  the  reverse  is  true.  Formerly  the  thymus 
was  supposed  to  reach  its  maximum  at  birth,  and  subsequently  to 
atrophy,  but  more  recent  observations  have  shown  that  remnants  per- 
sist until  puberty,  and  that  true  thymus  tissue  may  persist  throughout 
hfe. 

In  status  ly7?iphaticus  the  thymus  often  weighs  5  to  10  times  more 
than  normal.  In  well-marked  cases  its  weight  may  be  as  high  as  55  gm. , 
and  in  less  pronounced  cases  range  between  10  and  20  gm.  As  a  whole, 
the  hypertrophied  thymus  is  a  little  more  vascular  than  normal,  but 
aside  from  hyperplasia,  shows  no  other  consistent  changes  macroscop- 
ically  or  microscopically. 

Palpation. — Palpation  of  the  thymus  does  not  give  any  points  by 
which  to  estimate  its  size.  The  deformity  commonly  known  as 
"pigeon-breast"  is  not  even  remotely  associated  with  an  enlarged 
thymus. 

Functions. — Physiology. — The  physiology  of  the  thymus  is  indeed 
very  obscure,  little  being  known  about  its  functions.  Its  closeness  to 
the  thyroid  and  parathyroid  glands  and  its  similarity  of  origin  would 
almost  suggest  that  it  played  some  specific  part  in  metabolism,  but 
physiologic  experiments  of  late  have  failed  to  discover  exactly  what  this 
influence  is. 

During  the  past  few  years  there  has  been  considerable  experimenta- 
tion relative  to  the  thymus,  which,  so  far,  has  apparently  cleared  up  the 
matter  in  two  directions,  namely:  the  relation  of  the  organ  to  bone 
growth  and  to  the  condition  of  the  bones,  on  one  hand,  and  to  the 
electric  excitability  of  the  nerves  on  the  other.  Basch  has  shown  that 
following  complete  extirpation  of  the  thymus  in  a  j^oung  dog  there 
occurs  a  softening  of  the  bones  and  a  check  to  their  growth ;  in  fact,  a 
condition  very  much  resembling  rickets  and  chondrodystrophy.  At 
the  same  time  the  peripheral  nervous  system  shows  an  increased  electric 
excitability.  Numerous  other  observers  have  confirmed  these  observa- 
tions, and,  in  addition,  have  noted  that  in  thymectomized  animals 
there  exists  a  stage  of  increased  fat  absorption  and  later  malnutrition 
and  cachexia. 

STATUS  LYMPHATICUS 

It  is  well  proved  by  a  long  series  of  cases,  carefully  studied  by  com- 
petent observers,  that  the  condition  known  as  status  lymphaticus  is  an 
entity  and  is  characterized  clinically  by  a  lowered  vitality  or  an  un- 
stable equilibrium  of  the  vital  forces,  so  that  accidents  or  disturbances, 
otherwise  unimportant,  such  as  some  slight  injury  or  anesthesia,  may 
precipate  failure  of  the  heart  and  respiration. 

In  status  lymphaticus  there  is  hyperplasia  of  the  thymus  and  some- 
times general  lymphatic  gland  involvement. 

Pathology. — The  thymus  often  weights  5  to  10  times  more  than 
normal.  In  well-marked  cases  its  weight  may  be  as  high  as  55  gm., 
and  in  less  pronounced  cases  range  between  10  and  20  gm.  As  a  whole 
the  hypertrophied  thymus  is  a  little  more  vascular  than  normal,  but 


STATUS    LYMPHATICUS 


425 


aside  from  hyperplasia,  shows  no  other  consistent  changes  macroscop- 
ically  or  microscopically. 

Autopsy  findings  in  these  subjects  usually  show  a  general  lymphatic 
enlargement  of  tonsils  and  follicles  at  the  base  of  the  tongue  and  intes- 
tine and  swelling  and  enlargement  of  the  thymus,  especially  at  an  age 
when  it  has  generally  disappeared. 


Fig.  52. — Enlarged  Thymus.  The  lungs,  heart,  and  thymus  are  shown  in  the 
picture.  The  lungs  have  been  turned  back,  showing  the  two  lateral  lobes  of  the 
thymus  overlapping  the  heart;  the  central  lobe,  above,  covers  the  trachea. 
History. — Breast  fed,  male  child,  nine  months  old,  well  developed;  ill  less  than 
twenty-four  hours;  dyspnea,  slight  cyanosis,  with  death  from  asphyxia.  T.  103°F. 
Autopsy. — Besides  the  large  thymus  there  were  present  the  general  lesions  of  the 
status  lymphaticus  to  a  marked  degree;  lungs  deeply  congested  (from  Holt's 
"Diseases  of  Children,"  D.  Appleton  and  Company,  Publishers). 

Etiology. — An  explanation  of  the  disease  worth  recording  has 
never  been  offered.  The  symptoms  may  be  almost  identical  with 
laryngismus  stridulus.  There  are  sudden  repeated  at-tacks  of  croupy 
voice,  inspiratory  obstruction,  cyanosis,  apnea,  and  loss  of  conscious- 
ness which  may  last  from  a  few  seconds  to  minute  or  two.  In  not  every 
instance  is  the  above  sequence  of  events  carried  out.  The  attacks  may 
cease  at  any  stage,  or  the  child  may  never  recover  consciousness. 

The  above  clinical  picture,  with  later  proved  thymic  death,  has 
occurred  under  my  own  observation  several  times.     On  the  other  hand 


426  THE    PRACTICE    OF    PEDIATRICS 

the  first  sign  of  trouble  in  two  perfectly  well-nourished  infants  was  a 
convulsion  and  both  children  died  in  the  seizure.  There  had  never  been 
a  previous  convulsion  or  laryngeal  stridor.  Autopsy  in  both  showed  an 
enlarged  thymus. 

Cause  of  the  Sudden  Death. — The  explanation  of  the  deaths  occur- 
ring in  these  infants — most  frequently  during  the  first  eighteen  months 
— is  very  difficult,  and  in  many  cases  a  careful  autopsy  does  not  clear  up 
the  situation.  Many  extraordinary  hypotheses  have  been  advanced. 
Some  believe  that  pressure  exerted  by  the  hyperplastic  thymus  on  the 
vital  organs  in  this  region  is  sufficient  to  account  for  the  deaths. 
Others  are  convinced  that  the  pressure  exerted  by  this  gland  is  suffi- 


Normal  medias- 
inum 


Heart 


53. — Normal  thymus. 


cient  to  produce  tracheal  stenosis,  although  such  a  belief  seems  far 
fetched  when  one  considers  the  weight  of  the  thymus  and  contrasts  it 
with  the  fibrous  tracheal  rings. 

The  occurrence  of  a  sudden  swelling  has  not  yet  been  proved, 
neither  has  the  theory  of  a  narrowed  thoracic  outlet,  which  might  be 
still  more  narrowed  by  a  forceful  extension  of  the  head,  received  much 
support.  It  does  not  seem  possible  that  such  a  powerful  vessel  as  the 
aorta,  which  is  capable  of  eroding  bones,  could  be  pressed  upon,  with 
fatal  results,  as  is  suggested  by  some  authors. 

Many  of  the  sudden  deaths  occurring  during  chloroform  and  ether 
anesthesia  have  proved  to  be  due  to  status  lymphaticus. 

According  to  Paltauf's  many  extensive  observations,  the  cause, 
apparently  impossible  to  explain,  lies  in  a  peculiar  constitutional 


STATUS    LYMPHATICUS 


427 


anomaly,  which  makes  its  possessor  weak,  and  less  able  to  stand  attacks 
of  illness,  death  being  easily  produced  from  trifling  causes. 

Diagnosis. — Other  than  the  clinical  signs  we  have  the  Roentgen 
ray  and  percussion  to  aid  us  in  diagnosis. 

Percussion. — Percussion  of  the  thymus  has  been  carefully  studied 
by  Blumenreich,  and  is  of  much  greater  value  than  palpation,  although 
neither  of  these  methods  have  received  much  support  in  this  country. 
Many  instruments  have  been  devised  for  percussion,  but  no  two  men 
agree  on  the  results  obtained. 

Blumenrich  found  the  dulness  of  the  thymus  to  cover  a  space  some- 
what triangular  in  outline,  the  base  being  represented  by  a  line  drawn 
across  the  top  of  the  manubrium  between  the  sternoclavicular  joints, 


Enlarged 
thymus 


Heart 


Fig.  54. — Enlarged  thymus. 


while  the  rounded-off  point  or  apex  was  found  to  lie  about  on  a  line 
with  the  second  rib.  Between  this  thymus  dulness  and  the  normal 
cardiac  dulness  on  the  left  side  is  a  zone  normally  filled  in  by  lung  tis- 
sue ;  if  this  area  be  dulled  and  if  all  other  causes  of  impairment  can  be 
excluded,  then  a  diagnosis  of  enlarged  thymus  is  justifiable.  Among 
other  workers  the  names  of  Basch  and  Rohn  may  be  mentioned.  In 
their  outlining  of  the  thymus  they  found  it  to  be  more  rhomboid 
in  contour,  but,  on  the  whole,  tended  to  confirm  the  older  work  of 
Blumenreich. 

Roentgen  Ray. — Roentgen  ray  examinations  have  been  as  a  rule 
unsatisfactory  in  my  cases.  Figs.  53  and  54  represent  a  radiograph  by 
Cole  of  New  York  in  which  a  normal  and  an  enlarged  thymus  are  shown. 
The  radiograph  showing  the  enlarged  thymus  was  made  from  a  patient, 


428  THE    PRACTICE    OF    PEDIATRICS 

five  months  of  age.  The  child  was  premature  and  had  shown  since 
birth  a  tendency  to  attacks  of  mild  cyanosis.  The  child  was  nursed  by 
the  mother  and  made  satisfactorj'-  progress  along  nutritional  lines. 
Without  any  illness  or  the  occurrence  of  anything  of  a  nature  to  explain 
the  seizure,  the  child  became  markedly  cyanosed,  respirations  ceased  and 
the  child's  life  was  despaired  of.  Under  active  stimulation  and  arti- 
ficial respiration  by  the  trained  nurse  in  charge,  respiration  was  with 
much  difficulty  re-established.  During  the  next  few  weeks  there  were 
attacks  of  cyanosis  of  a  less  serious  nature.  Roentgen  ray  treatment 
was  caii'ied  out  by  Cole.  There  has  been  no  attacks  of  cyanosis  for 
several  months.     The  child  apparently  has  completely  recovered. 

Treatment. — Removal  of  the  thymus  has  been  practised  on  a 
limited  scale  with  unsatisfactory  results.  The  mortality  is  high  and 
with  the  thj^mus  removed  there  is  the  probability  of  defective  growth 
and  development  as  has  been  observed  in  thymectomized  animals. 

The  Roentgen  Ray. — Treatment  by  means  of  the  x-ray  has  been 
successfully  carried  on  by  Friedlander.*  In  my  own  patients  five  have 
been  given  the  x-ray  treatment.  I  am  not  prepared  to  pass  upon  its 
value. 

DYSPITUITARISM.     DYSTROPHY  ADIPOSOGENITALIS   (FROHLICH) 

This  disease  represents  the  manifestation  in  the  organism  of  di- 
minished function  of  the  anterior  lobe  of  the  pituitary  gland.  The 
loss  of  function,  according  to  Cushingf  may  be  due  to  tumor  pressure  or 
disease.  This  portion  of  the  gland  is  associated,  according  to  this 
author,  with  the  metabolism  of  fat,  with  sexual  activities,  and  is  closely 
related  in  an  obscure  way' with  the  functions  of  all  the  other  ductless 
glands  in  the  body.  Gushing  believes  that  sexual  infantilism  is  due 
to  diminished  secretions  of  the  pituitary  body,  there  not  being  sufficient 
to  activate  testicular  and  ovarian  functions. 

Symptoms. — In  this  disease  the  patient  is  short  in  stature,  very  fat 
and  with  a  marked  lack  of  sexual  development,  the  penis  and 
testicles  in  boys  remaining  almost  infantile  in  size.  There  is  an 
absence  of  pubic  hair  in  both  sexes.  Boys  show  decidedly  feminine 
characteristics. 

Six  cases  of  dyspituitarism  have  come  under  my  observation. 
5  were  boys,  ranging  from  eight  to  sixteen  years.  I  have  seen  but  one 
case  in  a  girl,  ten  years  old. 

Treatment. — The  administration  of  the  anterior  lobe  extract  is 
advised  by  Gushing  in  hypo-pituitarism.  He  states  that  many  of 
these  cases  have  been  benefited  in  the  past  by  thyroid  administration, 
due  to  an  indirect  reawakening  of  the  activities  of  the  hypophysis  and 
possible  secondary  activities  in  the  semative  organs. 

The  administration  of  thyroid  in  small  doses,  one-fifth  of  a  grain 
three  times  daily  with  three  grains  of  anterior  lobe  extract,  have  shown 
no  appreciable  results  in  my  own  cases. 

*  American  Journal  Diseases  of  Children,  vol.  vi,  p.  38-56. 
t  Journal  A.  M.  A.,  July  24,  1909,  p.  249. 


Xn.  THE  UROGENITAL  SYSTEM 
The  Urine 

Tables  dealing  with  the  frequency  of  urination  and  the  specific 
gravity  of  the  urine  for  the  different  ages  of  childhood  are  necessarily 
inaccurate,  particularly  when  they  refer  to  children  under  one  year  of 
age. 

Urinary  Observations. — At  the  New  York  Infant  Asylum  several 
years  ago  Dr.  George  T.  Myers,  at  that  time  resident  physician,  made 
a  series  of  investigations  under  my  direction  relating  to  the  various 
phases  and  functions  of  the  newly  born  infant,  which  differed  from  some 
of  the  observations  previously  recorded.  The  series  comprised  45  cases. 
Among  other  observations  was  one  as  to  the  time  of  the  first  micturi- 
tion after  birth.  It  was  found  that  the  time  varied  greatly.  In  fifteen 
micturition  occurred  simultaneously  with  birth;  in  ten,  in  less  than  four 
hours;  in  eight,  in  from  four  to  eight  hours;  and  in  the  remainder, 
ranged  between  eight  and  eighteen  hours  after  birth.  In  but  two  cases 
was  the  interval  longer  than  fourteen  hours.  It  was  also  found  that  the 
specific  gravity,  the  frequency  of  urination,  and  the  amount  of  urine 
passed  were  subject  to  wide  variations  within  normal  limits.  These 
various  features  depended  upon  whether  the  infant  was  breast-fed  or 
bottle-fed,  whether  a  girl  or  a  boy,  and  whether,  if  the  baby  was  breast- 
fed, the  mother  had  a  scanty  or  a  free  flow  of  milk.  The  bottle-fed 
always  passed  more  urine  than  the  breast-fed.  The  quantity  of  urine 
is  also  influenced  by  the  clothing  worn  and  by  the  season  of  the  year. 

Normal  Variations. — Normal  variations  occur,  therefore,  within  very 
wide  limits.  One  child  will  pass  urine  every  thirty  minutes  when 
awake;  others,  of  equal  health  and  age,  will  retain  it  for  three  hours. 
Before  the  child  takes  much  fluid,  particularly  in  the  first  days  of  life, 
from  two  to  five  ounces  is  probably  passed  in  twenty-four  hours,  with 
a  specific  gravity  of  1.005  to  1.010.  Infants  urinating  very  frequently 
are  apt  to  develop  into  bed-wetters  in  later  life,  probably  owing  to  the 
undeveloped  condition  of  the  bladder,  the  size  of  that  viscus  remaining 
small.  In  other  respects,  very  frequent  urination,  in  the  absence  of 
signs  of  illness,  is  of  no  significance  in  the  young.  After  the  feeding  is 
established,  the  specific  gravity  will  range  from  1.003  to  1.012  from 
the  second  week  to  the  second  year.  A  baby  nine  months  old  will  pass 
an  average  of  about  twelve  ounces  of  urine  in  twenty-four  hours.  At 
the  sixth  year,  from  sixteen  to  twenty-five  ounces  with  a  specific  gravity 
under  1.015  will  be  passed.  From  this  age  until  puberty  both  the 
quantity  and  specific  gravity  gradually  increase,  the  usual  range  in 
specific  gravity  being  from  1.010  to  1.020. 

429 


430  THE    PRACTICE    OF    PEDIATRICS 

Method  of  Collecting  Urine. — The  collection  of  the  amount  voided 
in  twenty-four  hours  by  children  of  the  "runabout"  age  is  difficult, 
and  in  young  infants  well-nigh  impossible,  except  in  a  metabohsm  bed. 
For  accurate  work  the  specimen  should  be  obtained  by  the  catheter. 
When  for  any  reason  this  is  not  possible,  there  are  various  devices  for 
collecting  the  urine,  any  one  of  which  may  be  tried.  The  tying  on  of 
a  wide-mouthed  bottle  or  a  condom  in  boys,  fastening  it  with  adhesive 
strips  to  the  body,  is  often  successful.  Absorbent  cotton  into  which 
the  child  urinates,  the  urine  being  expressed  from  this  into  a  bottle,  may 
be  used  for  either  boys  or  girls,  as  may  also  the  Chapin  collector.  The 
chief  disadvantage  of  any  of  these  measures  is  the  certainty  of  con- 
tamination. The  urine  so  collected  may  answer  for  an  examination  for 
albumin,  sugar,  or  the  renal  elements,  but  is  useless  for  a  bacteriologic 
study. 

Continence  Established. — From  the  second  to  the  third  year  conti- 
nence at  night  is  usually  established.  If  incontinence  continues  after 
the  third  year,  the  case  should  be  looked  upon  as  abnormal  and  receive 
treatment  accordingly.     (See  Incontinence  of  Urine,  p.  432.) 

DIFFICXJLT  AND  PAINFUL  URINATION 

Painful  urination  is  of  frequent  occurrence  in  infants  and  "run- 
about" children.  It  may  be  due  to  irritation  at  the  urethral  outlet 
following  injury,  or  to  scalding  from  acid  urine.  Not  infrequently  the 
irritation  is  due  to  lack  of  cleanliness  of  the  parts.  In  boys  with  long 
foreskins  which  remain  moistened  the  urine  undergoes  decomposition, 
and  inflammation  about  the  orifice  of  the  urethra  is  the  result.  In  girls 
dysuria  is  often  due  to  a  hardly  discernible  inflammation  about  the 
orifice  of  the  urethra,  occurring  in  association  with  vulvitis  or  vulvo- 
vaginitis. 

In  two  cases  I  have  found  calculi  in  the  urethra.  Both  patients 
were  boys  about  five  years  of  age.  By  far  the  greater  number  of  pa- 
tients who  suffer  from  difficult  micturition  are  boys  who  have  phimosis 
with  adhesions  and  retained  smegma.  Attention  to  the  external  geni- 
tals in  the  matter  of  cleanliness,  the  operation  of  circumcision,  or  the 
reUef  of  adhesions  by  slitting  the  foreskin  and  freeing  the  glans  promptly 
reheves  the  condition.  Among  the  operative  procedures,  only  cir- 
cumcision should  be  employed.  As  a  temporary  measure  the  dorsal 
slit  may  suffice. 

RETENTION  AND  SUPPRESSION  OF  URINE 

In  using  the  above  terms  with  reference  to  diseases  of  the  urinary 
organs  it  is  well  to  appreciate  their  significance.  By  suppression  is 
meant  a  condition  of  anuria  in  which  no  urine  is  passed  into  the  bladder, 
that  viscus  being  found  empty  on  catheterization.  In  retention  the 
urine  is  secreted  by  the  kidneys  and  passed  into  the  bladder,  but  is  not 
voided.     When    the  urine  is  not  voided,  we   must  always  ascertain 


EETENTION    AND    SUPPRESSION    OF    URINE  431 

whether  there  is  suppression  or  retention.  If  there  is  retention,  this 
fact  may  usually  be  discovered  by  palpation  and  percussion.  In  fat 
children  a  positive  diagnosis  may  be  impossible  by  this  means.  In  the 
event  of  doubt,  a  catheter  should  be  employed.  For  infants  under  one 
year  of  age  a  soft-rubber  catheter,  No.  4  or  5  American,  should  be  used. 
The  bladder  of  the  infant  and  young  child  is  very  readily  infected  and 
care  should  be  exercised  to  have  the  catheter  sterile.  If  suppression  is 
diagnosed  and  treatment  by  diuretics  is  instituted,  when  actually  there 
is  simple  retention,  no  httle  trouble  will  result,  as  I  have  occasionally 
seen. 

Suppression  of  the  urine  may  persist  for  hours  without  any  grave 
pathologic  condition  of  the  kidneys.  Chilling  of  the  skin  surface  may 
be  a  cause.  In  acute  gastro-intestinal  disorders  with  frequent  vomiting 
and  watery  stools  suppression  may  exist  for  twenty-four  hours.  The 
secretion  is  reestablished  when  there  is  again  an  available  fluid  to  be 
added  to  the  circulation  from  the  digestive  tract.  If  the  suppression 
is  due  to  causes  of  a  grave  nature,  such  as  acute  nephritis,  there 
will  usually  be  signs  of  other  trouble,  such  as  vomiting,  fever,  and 
edema. 

Retention  may  result  from  an  injury  to  the  urethra,  or  from  vagi- 
nitis, or  from  phimosis.  Impacted  stone  in  the  urethra  was  a  cause  in 
two  boys  seen  by  me.  Fortunately  in  each  case  the  stone  was  located 
near  the  meatus  and  readily  removed. 

Treatment. — Retention. — The  immediate  relief  of  retention  is  by 
catheterization.  Further  treatment  consists  in  the  correction  of  the 
exciting  cause.  If  a  catheter  is  not  at  hand,  the  application  of  a  hot 
stupe  over  the  lower  portion  of  the  abdomen  and  the  genitals  may  be 
sufficient  to  stimulate  urination. 

Suppression. — Colon  flushing  is  one  of  the  most  effective  measures 
of  relieving  suppression  of  the  urine.  The  apparatus  required  and  the 
methods  employed  will  be  found  on  page  795.  If  the  temperature  of 
the  patient  is  not  above  102°F.,  normal  salt  solution,  at  a  temperature 
of  110°F.,  is  advised.  I  have  always  found  flushing  more  effective 
when  this  degree  of  heat  was  used.  One  pint  is  introduced  for  a  child 
three  years  of  age.  In  children  of  one  year  or  under,  from  4  to  8  ounces 
is  all  that  will  be  retained.  The  enema  must  not  be  repeated,  however, 
oftener  than  once  in  six  or  eight  hours,  as  the  colon  of  a  child  soon  be- 
comes intolerant  of  the  injections  and  but  little  will  be  retained.  Re- 
peatedly, after  the  first  injection,  the  kidneys  have  resumed  activity 
when  all  other  means  had  failed.  This  method  has  been  particularly 
useful  in  cases  following  or  accompanying  the  exanthemata,  when 
there  was  an  acute  nephritis  with  greatly  diminished  secretion  of  urine. 
A  large  hot  poultice  of  flax-seed  meal  about  2  inches  thick  and 
sufficiently  large  to  cover  the  lumbar  and  lower  dorsal  regions  will 
often  act  surprisingly  well  in  establishing  the  kidnej^  function.  The 
treatment  should  be  continued  for  at  least  one  hour,  using  three 
poultices  during  this  time. 


432  THE    PRACTICE    OF    PEDIATRICS 

INCONTINENCE  OF  URINE  (ENURESIS) 

In  enuresis  there  is  an  involuntary  emptying  of  the  bladder. 

Enuresis  diuriia  is  the  involuntary  emptying  of  the  bladder  during 
the  waking  hours. 

Enuresis  nodurna  is  the  involuntary  emptying  of  the  bladder  during 
sleep. 

Involuntary  discharge  of  the  urine  is  normal  in  the  young  infant. 
Urination  becomes  a  voluntary  function  at  an  age  depending  largely 
upon  the  child's  training.  In  most  children,  with  the  right  kind  of 
management,  the  function  may  be  controlled  during  waking  hours  by 
the  tenth  month. 

During  sleep,  involuntary  urination  continues  to  a  later  period,  and, 
while  in  many  perfect  control  may  be  established  at  the  completion  of 
the  second  year,  I  do  not  regard  the  lack  of  control  as  abnormal  until 
the  third  year  is  completed.  If,  during  the  second  year,  the  child 
shows  a  tendency  to  frequent  urination  and  involuntary  passage  of 
urine  during  the  waking  hours,  with  habitual  incontinence  at  night,  it 
is  my  custom  to  advise  preventive  measures. 

When  the  incontinence  persists  during  the  waking  hours  at  the 
completion  of  the  second  year,  or  during  sleep  at  the  completion  of  the 
third  year,  the  condition  is  regarded  as  abnormal  and  the  child  is  placed 
under  treatment. 

Etiology. — Deformities  and  Abnormalities. — The  condition  may  be 
due  to  a  congenitally  small  bladder,  with  very  little  holding  capacity. 
A  girl  who  came  under  my  care  for  treatment  for  incontinence  by  day 
and  night  had  a  bladder  the  holding  capacity  of  which  was  but  one 
ounce.  With  such  lack  of  development  of  the  bladder,  obviously  there 
must  be  incontinence.  In  spina  bifida  it  may  occur  as  a  result  of 
paralysis  of  the  pudic  nerve  supply  to  the  neck  of  the  bladder;  a  con- 
genitally large  urethra  may  also  be  a  cause. 

Peripheral  causes  acting  through  reflex  irritation  are  not  infre- 
quently encountered. 

Thus,  incontinence  may  be  due  to  a  vaginitis,  to  an  adherent 
clitoris,  or  to  phimosis.  It  may  be  due  to  thread-worms  in  the  rectum, 
to  constipation,  to  stone  in  the  bladder,  to  cystitis,  or  to  hyperacidity  of 
the  urine. 

The  diet  may  also  play  a  part.  The  use  of  highly  nitrogenous  food 
in  large  amounts  or  a  diet  rich  in  sugar  may  lead  to  changes  in  the  urine 
sufficient  to  cause  the  trouble. 

Excessive  bed-clothing  and  the  habit  of  sleeping  on  the  back  have  a 
bearing  in  the  causation. 

Adenoid  vegetations  in  considerable  amount  in  the  nasopharyngeal 
vault  are  looked  upon  by  some  authors  as  an  etiologic  factor.  Those 
afflicted  with  diabetes  insipidus  (polyuria)  or  diabetes  mellitus,  because 
of  the  large  amount  of  urine  passed,  are  very  apt  to  sufl'er  from 
incontinence. 

Weakness  of  the  sphincter  is  supposed  to  play  a  part  in  causing  in- 
continence, particularly  loss  of  control  when  awake. 


INCONTINENCE    OF    URINE    (ENURESIS)  433 

Cases  of  Nervous  Origin. — The  nervous  control  of  the  bladder  is 
dependent  upon  a  cerebral  center  and  a  sacral  center,  each  receiving 
and  sending  out  impulses. 

It  is  not  difficult  to  understand  how  a  lack  of  coordination  from 
faulty  development  of  the  sympathetic  mechanism  might  occasion  in- 
continence. After  all  possible  dietetic  errors  and  irritations  acting  re- 
flexly  through  the  above  nerve  mechanism  are  excluded,  about  90  per 
cent,  of  our  cases  remain  unexplained.  This  group  represents  the  cases 
usually  chronicled  as  due  to  a  neurosis,  absence  of  coordination  due  to 
failure  of  sufficient  development  of  the  nerve-centers. 

Diagnosis. — The  patient  always  has  a  ready-made  diagnosis. 

Prognosis. — The  prognosis  depends  largely  upon  the  physician  and 
the  child's  parents  or  attendant.  Great  patience  and  persistence  are 
necessary.  All  cases  are  curable  except  when  an  anatomic  abnormality 
exists.  In  many  instances  the  response  to  treatment  is  very  prompt. 
In  others  it  is  tedious,  several  months  being  required  before  we  are 
sure  that  the  cure  is  complete. 

A  fact  to  be  taken  into  consideration  in  making  a  prognosis  as  to 
the  probable  duration  of  the  treatment  in  a  given  case  is  the  size  of  the 
bladder,  since  a  child  who  has  suffered  from  incontinence  both  by  day 
and  night  may  have  a  small  and  contracted  bladder,  because  of  lack  of 
development  from  disuse.  The  most  reliable  means  of  determining  the 
size  of  a  bladder  is  by  measuring  the  amount  of  sterile  water  which  can 
be  introduced  through  a  catheter. 

Treatment. — In  assuming  the  care  of  a  child  with  enuresis,  obviously 
it  is  most  necessary  to  learn  the  cause  of  the  trouble.  Two  or  three 
examinations  of  the  urine  should  be  made,  and  if  this  is  found  persist- 
ently acid  and  of  a  specific  gravity  over  1020,  a  reduction  in  the  ni- 
trogenous food-stuffs  is  necessary  before  beginning  medication.  If  the 
enuresis  is  due  to  peripheral  causes,  they  must  be  corrected  and  the 
general  physical  condition  of  the  child  improved,  although  in  ray  ex- 
perience the  delicate  and  chronically  ailing  are  not  the  children  who 
are  the  greatest  sufferers,  by  far  the  larger  number  of  my  patients  hav- 
ing been  well-nourished  children  who  were  otherwise  normal.  Long- 
continued  incontinence  does  not  appear  to  affect  the  general  health. 
When  well  established,  the  condition,  untreated,  usually  continues 
until  the  child  is  eight  or  ten  years  of  age.  I  have  known  of  a  few  cases 
which  persisted  until  puberty,  or  later. 

If  no  improvement  follows  the  removal  of  aU  possible  dietetic  and 
peripheral  causes, — acidity,  phimosis,  worms,  constipation,  etc., — 
we  must  assume  that  we  have  an  idiopathic  incontinence  to  deal  with. 
If  the  case  is  one  of  nightly  incontinence  of  several  months'  or  years' 
standing,  we  must  positively  acquaint  the  mother  with  the  fact  that 
prolonged  treatment  will  in  all  probability  be  required,  and  that  unless 
her  active  and  continued  cooperation  is  assured  the  treatment  of  the 
case  will  not  be  undertaken. 

With  the  very  definite  understanding  that  no  brilliant  results  are 
immediately  expected,  the  following  scheme  of  management  is  inaugu- 
28 


434  THE    PRACTICE    OF   PEDIATRICS 

rated :  The  child  receives  three  meals  daily.  The  breakfast  and  dinner 
correspond  to  the  age  of  the  child,  but  with  the  important  exception 
that  red  meat  is  to  be  given  but  once  during  the  twenty-four  hours, 
and  only  at  midday.  The  supper,  which  should  not  be  later  than  6 
o'clock,  I  designate  as  a  "dry  supper."  It  may  consist  of  any  cereal, 
such  as  rice,  hominy,  farina,  or  wheatena,  served  with  butter  and  sugar. 
If  this  is  not  well  taken,  a  small  quantity  of  both  sugar  and  milk  may 
be  added.  Permissible  articles  for  the  evening  meal  in  addition  to  the 
above  are:  ice-cream,  milk  toast,  blanc-mange,  jelly,  stewed  fruit, 
bread  and  butter,  junket,  and  corn-starch.  Meat,  eggs,  or  heavy 
foods  of  any  kind  should  not  be  given  at  night. 

Abstinence  from  Fluids. — One  pint  of  water  and  one  pint  of  milk 
only  are  allowed  in  24  hours  in  persistent  cases.  At  4  o'clock  in  the 
afternoon  the  child  may  be  given  a  half-glass  of  water  or  milk,  but  after 
this  time  no  fluids  are  to  be  allowed  other  than  a  scant  ounce  of  miUc 
on  the  cereal.  The  withdrawal  of  all  fluids  after  4  p.  m.  will  at  first 
be  a  hardship  for  some  children,  and  they  may  be  allowed  three  or 
four  ounces  of  milk  or  water  with  the  evening  meal;  but  this  quantity 
should  gradually  be  diminished  until  at  the  end  of  a  week  it  will  not 
be  missed. 

Night  Management. — The  patient  should  be  as  lightly  covered  at 
night  as  comfort  will  permit.  There  is  less  tendency  to  incontinence 
if  the  child  rests  on  the  side  or  stomach,  and  sleep  in  this  position  should 
be  encouraged.  In  dealing  with  inveterates,  for  whom  every  possible 
aid  is  brought  into  use,  I  have  used  the  knotted  towel  as  a  means  of 
keeping  the  child  off  his  back.  The  towel,  knotted  in  the  middle,  is 
passed  around  the  child  so  that  the  knot  will  rest  on  the  back.  The 
ends  of  the  towel  should  then  be  pinned  together  over  the  abdomen  like 
those  of  an  abdominal  binder.  When  the  patient  attempts  to  rest  on 
the  back  the  knot  causes  discomfort  and  the  position  is  changed.  At 
10  or  11  o'clock,  when  the  person  in  charge  retires,  the  child  should  be 
taken  up  to  urinate. 

Drugs. — Without  a  strict  observation  of  the  above  measures,  par- 
ticularly those  referring  to  diet  and  abstinence  from  water  after  4  p.  m., 
drugs  are  of  no  value,  whatever  their  method  of  administration.  With 
the  above  suggestions  carried  out,  we  have  one  remedy  which  is  of  great 
value,  and  that  is  belladonna.  For  convenience  of  administration  I 
prefer  the  alkaloid,  atropin.  To  insure  full  benefit  in  severe  cases  the 
drug  must  be  pushed  until  we  obtain  the  physiologic  effect,  as  shown 
by  slight  dilatation  of  the  pupils.  Before  beginning  the  treatment  it  is 
well  to  advise  mothers  that  redness  of  the  skin  need  cause  no  alarm, 
but  calls  for  the  discontinuance  of  the  drug  until  further  instructions 
are  given.  The  atropin  is  administered  in  a  solution  of  one  grain  to  an 
ounce  of  water;  one  ounce  of  water  contains  approximately  500  drops, 
so  that  one  drop  of  the  atropin  solution  will  contain  approximately 
3^00  grain  of  the  drug.  The  mother  is  given  a  chart  containing  the 
directions  for  administration,  which  for  a  child  five  years  of  age  are  as 
follows : 


INCONTINENCE    OF    URINE    (ENURESIS)  435 

1st  day 4  p.  M.  0  drop  7  p.  m.  1  drop 

2d      "   "  1       "  "  1       " 

3d      "   "  1       "  "  2  drops 

4th    "  "  2  drops  "  2 

5th    "  "  2       "  "  3 

6th    "   "  3       "  "  3 

7th    "  "  3       "  "  4 

8th    "   "  4       "  "  4 

9th    "   "  4       "  "  5 

10th  "   "  5       "  "  5 

The  maximum  dose  given  is  one  drop  daily  at  4  and  7  p.  m.  for 
every  year  of  age.  Thus,  for  a  child  three  years  old  the  dosage  should 
not  be  greater  than  three  drops,  twice  daily;  for  a  child  six  years  old 
not  over  six  drops,  twice  daily.  It  may  be  well,  if  the  case  is  not 
under  close  observation,  to  make  a  more  gradual  increase  in  the 
dosage  than  the  above,  so  as  to  avoid  the  possibility  of  unpleasant 
physiologic  effects. 

It  is  never  necessary  to  exceed  these  doses  even  with  older  children, 
for  the  reason  that  the  amounts  given  are  sufficient  to  control  the 
enuresis;  and  the  dilated  pupils  and  belladonna  blush  which  follow  an 
increased  dosage  show  that  such  increases  are  imprudent. 

The  tolerance  of  atropin  varies  considerably,  although  children 
usually  bear  it  very  well.  Now  and  then  a  child  is  treated  who  cannot 
take  more  than  two  drops  (H50  grain)  daily.  To  one  boy  eight  years 
of  age  but  3^^ 00  grain  could  be  given  twice  daily. 

Pronounced  benefit,  ordinarily,  will  not  be  observed  during  the  first 
week  or  two  of  treatment.  If  the  child  suffers  from  incontinence  while 
awake,  this  will  first  be  cured.  The  improvement  in  nocturnal  incon- 
tinence is  more  gradual  and  may  be  considerably  delayed.  Thus,  no 
improvement  whatever  may  be  seen  for  two  or  three  weeks.  In  the 
average  case  the  improvement  is  gradual.  At  first  there  will  be  nights 
at  short  intervals  when  there  will  be  very  slight  incontinence,  or  none 
at  all.  Usually,  after  a  few  weeks'  treatment  the  incontinence  entirely 
ceases. 

The  mistake  frequently  made  is  to  stop  the  atropin  at  this  point. 
When  this  is  done,  there  is  usually  an  immediate  return  of  the  trouble. 
The  full  treatment  should  be  continued  until  the  child  has  not  wet  the 
bed  for  at  least  two  weeks.  The  daily  amount  of  atropin  should  then 
be  reduced  one-half  and  kept  at  this  point  for  six  weeks.  If  at  the  end 
of  two  months  from  beginning  treatment  there  is  no  incontinence,  the 
drug  may  be  discontinued,  but  the  dietetic  restrictions,  particularly  the 
"dry  supper,"  should  be  maintained  three  months  longer.  It  must  be 
remembered  that  the  habit  which  has  become  established  is  hard  to 
overcome,  even  after  the  neurosis  and  the  weakness  of  the  sphincter 
have  been  corrected. 

Strychnin  and  tincture  of  cantharides  have  been  advocated  by 
pediatric  writers.  For  weak,  poorly  nourished  children  strychnin 
added  to  the  iron  or  oil  may  be  of  service  in  improving  the  general  con- 
dition of  the  patient,  and  indirectly  aid  in  the  treatment  of  the  enuresis. 

When  incontinence  occurs  only  during  the  day,  the  dietetic  regula- 


436  THE    PRACTICE    OF    PEDIATRICS 

tions  are  the  same,  with  the  exception  that  the  fluids  allowed  need  not 
be  curtailed  unless  the  quantity  is  excessive.  The  dosage  of  atropin  is 
the  same,  but  the  time  of  administration  should  be  changed  to  after 
breakfast  and  after  luncheon,  instead  of  at  4  and  7  p.  m.  In  addition 
to  the  atropin,  strychnin  should  always  be  given  in  cases  of  inconti- 
nence by  day,  for  in  such  cases  a  lack  of  development  or  a  relaxation  of 
the  s  hincter  is  more  of  a  factor  than  is  failure  of  nerve  coordination. 

HEMATURIA  (BLOOD  IN  THE  URINE) 

The  presence  of  blood  in  the  urine  may  be  due  to  readily  discernible 
causes;  or  when  small  (microscopic)  amounts  are  present,  the  cause 
may  be  most  difficult  to  determine. 

Highly  concentrated  urine  may  be  sufficiently  irritating  to  produce 
the  passage  of  microscopic  amounts  of  blood.  Blood  and  albumin  are 
not  of  infrequent  occurrence  in  the  urine  of  the  newly  born  and  during 
the  first  weeks  of  life,  because  of  the  presence  of  uric  acid  in  large 
amounts  peculiar  to  this  period  of  life. 

Among  the  possible  causes  of  blood  in  the  urine  are: 

Acute  nephritis. 

Scarlatina. 

Hemophilia. 

Purpura  haemorrhagica. 

Scurvy. 

Trauma. 

Calculi. 

Malignant  growth  of  the  kidney. 

Tuberculosis  of  the  kidney  or  bladder. 

Certain  drugs  taken  into  the  stomach. 

HEMOGLOBINURIA 

In  this  condition  the  urine  contains  the  coloring-matter  of  the  blood, 
with  few,  if  any,  corpuscles.  There  may  be  a  small  amount  of  albumin. 
The  urine  may  be  light  red,  brown,  or  even  black.  In  a  child  one  year 
old  who  died  from  creasote  poisoning  the  urine  was  almost  black.  This 
case  was  seen  in  consultation.  In  another  case  of  a  child  three  years 
of  age  with  malaria  the  urine  was  of  a  deep  brown  color. 

Paroxysmal  hemoglobinuria  is  of  very  rare  occurrence  in  this 
country.  In  tropical  countries,  where  severe  forms  of  malaria  are 
common,  the  condition  is  not  unusual.  It  is  due  to  some  atoxic  agent 
or  ferment  which  dissolves  the  coloring-matter  out  of  the  blood. 

PYURIA 

Pus  in  the  urine  in  the  young  is  usually  the  result  of  a  cystitis, 

cystopyelitis,  or  pyonephrosis. 

Illustrative  Case. — A  hospital  patient,  about  eighteen  months  of  age,  showed 
periodically  large  amounts  of  pus  in  the  urine.  Pus  would  be  present  in  the  urine 
for  a  few  hours,  and  then,  for  two,  three,  or  more  days,  the  urine  would  be  perfectly 
clear  and  free  from  pus. 


GLYCOSURIA  437 

Autopsy  showed  that  although  one  kidney  was  normal,  the  other  had  undergone 
cystic  degeneration,  the  pelvis  being  greatly  dilated  and  filled  with  pus.  The  ureter 
was  thickened  and  partially  occluded.  When  the  sac  had  become  filled  with  pus, 
and  the  child  was  in  a  favorable  position,  the  pus  probably  discharged  into  the 
bladder. 

Pyelonephritis  may  be  the  result  of  a  pyelocystitis. 

Illustrative  Case.— A  child  eleven  months  of  age  had  pyelitis,  evidently  pri- 
marily, which  had  not  been  recognized.  The  temperature  ranged  very  high, — 
105°  to  107°F., — and  the  child  died  from  exhaustion  and  anemia.  Autopsy 
revealed  an  extensive  pyelitis  with  multiple  abscesses  scattered  throughout  the 
kidney  structure,  varying  in  size  from  a  pin-point  to  a  pea. 

Such  cases  as  the  foregoing,  it  is  understood,  are  of  very  unusual 
occurrence.  In  still  rarer  instances  the  pus  may  be  due  to  an  abscess, 
phrenic  or  of  other  type  which  may  open  into  the  urinary  tract. 
When  pus  is  present  in  the  urine,  the  source  is  usually  the  bladder 
(cystitis)  or  the  pelvis  of  the  kidney  (pyelitis). 

Specific  urethritis  (gonorrhea)  will  give  rise  to  pus  in  the  urine. 
Gonorrhea,  however,  is  of  very  unusual  occurrence  in  boys,  and  when 
present,  it  is  sufficiently  active  to  leave  no  doubt  as  to  the  nature  of  the 
trouble. 

GLYCOSURIA 

Temporary  glycosuria  or  dietetic  glycosuria  is  of  frequent  occur- 
rence and  little  significance.  This  condition  usually  means  that  more 
sugar  is  being  taken  than  can  be  cared  for  by  the  economy,  and  with  a 
discontinuance  of  the  excessive  intake  the  sugar  disappears  from  the 
urine. 

Illustrative  Cases. — In  a  series  of  observations  made  several  years  ago  at  the 
Country  Branch  of  the  New  York  Infant  Asylum,  10  children  were  selected  for 
high-sugar  feeding,  and  10  per  cent,  sugar  mixtures  were  given  to  those  under  one 
year  of  age.     Every  case  showed  glycosuria  after  twenty-four  hours  of  this  feeding. 

Two  most  interesting  cases  of  persistent  glycosuria  without  any  other  mani- 
festation of  illness  have  been  under  my  observation  for  the  past  eighteen  years. 
That  sugar  existed  in  the  urine  of  both  patients  was  discovered  by  accident.  How 
long  the  sugar  may  have  been  present,  we  have  no  means  of  knowing.  The 
mother,  an  unusually  careful  woman,  conceived  the  idea  that  it  would  be  wise  to 
have  the  urine  of  all  her  four  children  examined.  It  was  accordingly  sent  to  me, 
and  greatly  to  my  surprise  I  found  that  two  specimens,  one  from  a  boy  of  four 
years,  the  other  from  his  brother  of  six,  contained  a  large  amount  of  sugar — 3 
and  3.5  per  cent,  respectively.  A  careful  examination  was  at  once  made  of  both 
patients,  but  reA^ealed  nothing  abnormal.  The  children  were  strong;  there  was 
no  unusual  thirst  and  no  polyuria,  and,  further,  the  examination  of  the  urine  failed 
to  reveal  the  presence  of  either  acetone  or  diacetic  acid.  They  were  placed  on  a 
rigid  antidiabetic  diet  (p.  737),  which  reduced  the  sugar  to  1.5  and  2  per  cent, 
respectively.  During  the  eighteen  years  that  have  since  intervened  the  boys  have 
made  satisfactory  physical  and  mental  progress;  they  have  attended  school 
regularly,  except  when  prevented  by  the  usual  ailments  of  childhood.  Both  have 
undergone  operation  for  adenoids  and  enlarged  tonsils,  under  ether  anesthesia, 
with  no  more  than  the  usual  discomfort.  They  have  made  normal  increase  in 
stature,  weight,  and  strength,  and  are  perfectly  normal  in  appearance.  During 
these  years  monthly  examinations  have  been  made  of  the  urine.  There  has  never 
been  less  than  1.5  per  cent,  of  sugar  in  any  specimen.  The  sugar  has  rarely  been 
below  3  per  cent,  or  above  6  per  cent.  The  condition  has  persisted  in  spite  of  the 
most  careful  diet.  There  never  has  been  polyuria  or  extreme  thirst.  The  children 
have  been  seen  by  several  consultants  in  New  York  City,  and  have  been  under 
the  treatment  of  three  well-known  specialists  in  Germany.     Recently  acetone 


438  THE    PRACTICE    OF    PEDIATRICS 

has  been  found  in  the  urine  of  one.  Probably  every  variety  of  treatment  which 
might  be  expected  to  exert  an  influence  on  the  sugar-production  has  been  tried  for 
protracted  periods  without  exerting  a  particle  of  influence  in  reducing  it.  Indis- 
cretions in  diet  increase  the  sugar;  otherwise  it  varies  as  stated  above. 

The  cases  here  cited  in  detail  are  of  much  interest  as  showing  the  in- 
efficiency of  medication  and  the  effects  of  diet  in  glycosuria,  and,  fur- 
thermore, as  presenting  a  clinical  picture  which  is  most  unusual.  It 
has  been  suggested  that  the  glycosuria  in  these  cases  may  be  due  to 
some  persistent  and  unusual  toxemia  from  intestinal  sources. 


The  Kidneys 
tuberculosis  of  the  kidney 

Tuberculosis  of  the  kidney  is  usually  secondary  to  tuberculosis 
existing  elsewhere  in  the  body.  Primary  cases,  however,  have  been 
reported. 

Lesions. — In  general  tuberculosis  miliary  tubercles  are  scattered 
throughout  the  kidney.  In  other  forms  there  are  nodular  lesions,  or 
foci  of  caseation  which  may  break  down,  resulting  in  the  formation  of 
cavities. 

Symptoms. — The  symptoms  of  the  disease  are  progressive  weakness 
and  emaciation,  attended  by  a  low  grade  of  fever.  In  many  instances 
the  affected  kidney  is  enlarged  and  palpable.  Frequency  of  urination 
is  a  characteristic  symptom,  and  the  urine  may  contain  albumin, 
blood,  or  pus.  The  presence  of  blood  for  a  considerable  period  in 
urine  of  normal  specific  gravity  containing  no  casts  is  strongly  suggest- 
ive of  tuberculosis  of  the  kidney.  The  finding  of  the  tubercle  bacillus 
in  the  centrifuged  urine  substantiates  the  diagnosis.  Catheterization 
of  the  ureter  is  of  value  in  demonstrating  whether  one  or  both  kidneys 
are  involved. 

Prognosis. — The  prognosis  is  unfavorable. 

Treatment. — Tuberculin  therapy,  in  careful  hands,  may  be  of  value. 
In  all  cases  the  routine  supportive  treatment  followed  in  other  forms 
of  tuberculosis  should  be  employed.  When  one  kidney  remains  normal, 
the  best  results  are  gained  by  surgery  involving  extirpation  of  the 
diseased  organ. 

NEW-GROWTHS  OF  THE  KIDNEY 

Non -malignant. — Non-malignant  new-growths  of  the  kidney  are 
uncommon.  Adenomata  and  fibromata  are  occasionally  encountered. 
The  adenomata  are  either  papillary  or  cystic,  and  are  encapsulated  by 
connective  tissue.  These  growths  appear  as  small,  light-colored  nod- 
ules, and,  microscopically,  present  an  alveolar  or  tubular  structure. 
Fibromata  exist  as  white,  nodular  masses,  usually  not  over  3^  inch 
in  diameter.  They  are  imperfectly  differentiated  from  the  interstitial 
connective  tissue  of  the  kidney. 


HYDRONEPHROSIS  AND  PYONEPHROSIS  439 

Malignant. — Adenosarcomata  and  adenocarcinomata  are  two  forms 
described  in  the  literature.  Herringham*  emphasizes  the  fact  that  the 
degree  of  malignancy  of  such  growths  cannot  be  accurately  determined 
from  their  histologic  structure. 

Malignant  neoplasms  of  the  kidney  are  more  common  before  the 
fifth  year  of  life  than  in  any  succeeding  decade,  f  These  tumors  have 
been  classified  as  carcinomata  and  sarcomata.  Most  of  the  growths, 
however,  are  atypical  mixed  tumors  of  embryonic  origin,  and  may  con- 
tain striped  muscle,  cartilage,  and  lipomatous  or  fibrous  connective 
tissue. 

The  hypernephroma  is  derived  from  suprarenal  tissue,  which  may  be 
included  in  the  developing  kidney.  This  tumor  is  subject  to  great 
variations  in  size  and  structure,  and  may  resemble  sarcoma,  adenoma, 
carcinoma,  or  perithelioma.  The  growth  characteristically  contains 
pigment,  which  is  indentical  with  that  found  in  the  adrenal.  Not  in- 
frequently the  hypernephroma  becomes  cystic. 

Symptoms  of  Renal  Neoplasms. — Malignant  growths  of  the  kidney 
often  attain  an  enormous  size,  half  fiUing  the  abdominal  cavity  and 
displacing  certain  of  the  contained  organs.  The  abnormal  mass  is 
usually  movable  and  occasionally  communicates  pulsations  from  the 
subjacent  aorta.  The  edges  of  the  tumor  are  more  rounded  than 
those  of  an  enlarged  spleen  or  liver,  and  the  anterior  surface  is  less 
closely  related  to  the  ribs.  Apart  from  the  local  physical  signs,  the 
patient  may  present  no  significant  symptoms.  Nutrition,  however, 
is  generally  impaired,  and  in  many  instances  the  tumor  occasions 
dragging  pain  and  hematuria. 

Prognosis. — In  untreated  cases  the  course  of  the  disease  is  pro- 
gressive and  its  outcome  fatal.  Metastases,  however,  are  of  relatively 
slow  development,  and  are  preceded  by  involvement  of  the  veins  closely 
related  to  the  growth. 

Treatment. — Nephrectomy  is  the  only  treatment  of  value,  and  even 
this  is  useless  when  multiple  metastases  have  occurred. 

The  majority  of  the  cases  which  undergo  operation  develop  malig- 
nancy in  the  remaining  kidney  within  a  year  or  so  after  the  operation. 
A  very  exceptional  case  was  that  of  a  two-year-old  girl,  a  patient  at  the 
Babies'  Hospital  in  New  York  City.  From  this  child  Dr.  Robert 
Abbe  removed  a  large  kidney  sarcoma.  The  recovery  was  complete, 
and  the  patient  is  now  a  perfectly  weU  young  woman,  twenty-eight 
years  of  age. 

HYDRONEPHROSIS  AND  PYONEPHROSIS 

Hydronephrosis  is  a  condition  characterized  by  distention  of  the 
pelvis  of  the  kidney  with  an  accumulation  of  urine.  With  an  invasion 
of  the  contained  urine  by  the  colon  bacillus  or  other  pathogenic  organ- 
isms, a  pyonephrosis  develops.    ■ 

*  Kidney  Diseases,  1912,  p.  309. 

t  Herringham  on  Statistics  of  Morris,  Kidney  Diseases,  p.  311. 


440  THE    PRACTICE    OF    PEDIATRICS 

Etiology. — A  few  cases  of  traumatic  hydronephrosis  have  been 
reported.  Ordinarily,  however,  the  disease  develops  as  the  result  of 
some  obstruction  in  the  urinary  tract  which  may  be  either  congenital 
or  acquired. 

Congenital  hydronephrosis  may  be  due  to  an  angular  junction  of 
the  ureter  with  the  pelvis  of  the  kidney,  septa  or  valves  in  the  ureter, 
an  abnormally  small  ureterovesical  orifice,  twisting  of  the  ureter  by  a 
floating  kidney,  or  an  imperforate  urethra. 

Acquired  hydronephrosis  may  be  occasioned  by  inflammatory 
stricture  of  the  ureter,  an  obstructing  calculus,  or  external  pressure  on 
the  ureter  by  a  neighboring  tumor. 

Pathology. — The  ureter  is  dilated  and  perhaps  sacculated  above  the 
site  of  the  obstruction.  The  kidney  is  usually,  but  not  invariably,  en- 
larged, and  on  section  the  organ  will  be  found  to  be  structurally 
deficient  and  more  or  less  cirrhotic.  The  contained  fluid  resembles 
normal  urine,  but  contains  a  relatively  small  amount  of  urea.  In 
long-standing  cases  the  kidney  may  become  infected  and  undergo 
suppurative  inflammation.  In  such  instances  the  fluid  contents  be- 
come purulent  and  the  condition  resolves  itself  into  pyonephrosis. 
In  fact,  in  aU  my  cases  which  came  to  autopsy — 3  in  number — a 
pyonephrosis  was  present.  Usually  one  kidney  only  is  involved.  In 
two  of  my  cases  both  organs  were  affected,  the  pelvis  being  so  dilated 
as  to  be  almost  unrecognizable.  In  a  newly  born  babe  who  died  in 
five  days  both  kidneys  were  enlarged,  soft,  and  easily  palpable. 

Chronic  diffuse  nephritis  is  frequently  associated  with  hydro- 
nephrosis. 

Symptoms. — The  significant  manifestations  of  ''dropsy  of  the  kid- 
ney" are  localized  pain  and  tenderness,  a  fluid  tumor  in  the  kidney 
region,  and  scanty  urination,  which  may  be  interrupted  at  intervals  by 
the  discharge  of  urine  of  low  gravity  in  more  than  normal  amount. 
In  doubtful  cases  aspiration  of  the  fluid  from  the  tumor  may  facilitate 
the  diagnosis.  Pus  is  usually  present  in  the  urine,  and  through  cultures 
the  nature  of  the  infection  may  be  learned. 

Prognosis. — Children  suffering  from  bilateral  hydronephrosis  die 
in  early  infancy.  When  the  condition  is  unilateral,  the  patient  may 
survive,  provided  the  unaffected  kidney  is  in  other  respects  normal.  ■ 

Treatment. — Prophylactic  doses  of  uro tropin  have  been  adminis- 
tered to  forestall  possible  suppuration.  Surgery,  however,  offers  the 
best  possibilities,  and  the  only  operation  of  permanent  value  is 
nephrectomy. 

Illustrative  Case. — A  recent  case  presented  very  puzzling  symptoms.  There 
was  a  periodic  discharge  of  large  amounts  of  urine,  containing  free  pus,  casts,  and 
epithelial  cells.  The  phenomenon  occurred  about  every  second  or  third  day. 
Between  times  specimens  of  the  urine  obtained  by  catheter  were  normal.  The 
child  died  from  malnutrition  and  marasmus.  At  autopsy  one  kidney  was  found 
normal.  The  other  showed  a  typical  dilated  hydropyonephrosis,  with  the  upper 
two-thirds  of  the  ureter  dilated,  sacculated,  and  thickened.  In  the  lower  portion 
there  was  a  congenital  constriction  with  angulation  which  gave  way  when  the  pres- 
sure from  above  became  pronounced  and  the  kidney  contents  were  evacuated. 


ACUTE    PARENCHYMATOUS    NEPHRITIS  441 

CYSTS  OF  THE  KIDNEY 

Cysts  of  the  kidney  are  usually  congenital,  due  to  defective  embry- 
onic development.  These  cysts  occur  in  that  portion  of  the  organ 
which  is  developed  from  the  metanephros.  They  are  almost  always 
bilateral,  and  are  usually  associated  with  a  process  of  fibrosis  which 
replaces  a  variable  amount  of  the  parenchyma  of  the  affected  organ. 
In  many  of  the  patients  other  congenital  malformations  coexist. 

Retention  cysts  occasionally  arise  from  obstruction  along  the 
courses  of  the  uriniferous  tubules,  and  secondary  cystic  degeneration 
may  be  induced  in  a  kidney  which  is  the  seat  of  a  destructive  primary 
disease.  Hydatid  cysts  develop  occasionally  as  the  result  of  echino- 
coccus  invasion. 

Many  infants  with  congenital  cysts  of  the  kidney  die  in  the  first 
year  of  life. 

Symptoms  of  the  diseased  condition  are  unapparent,  or  else  are 
confined  to  the  local  signs  of  tumor,  and  such  manifestations  of  urinary 
retention  as  edema  and  uremic  convulsions.  Wyeth  states  that  it  is  a 
safe  rule  to  aspirate  the  contents  of  a  renal  tumor  which  is  large  enough 
to  be  appreciated  by  palpation  and  inspection.  If  this  be  done,  the 
fluid  from  congenital  cysts  will  be  found  to  resemble  that  from  a  hydro- 
nephrosis, that  from  a  hydatid  cyst  will  show  the  presence  of  booklets, 
and  that  from  an  organ  undergoing  cystic  degeneration  will  be  found 
to  be  highly  albuminous. 

When  treatment  of  cyst  of  the  kidney  is  justifiable,  the  procedure 
must  be  surgical. 

ACUTE  PARENCHYMATOUS  NEPHRITIS  (ACUTE  DIFFUSE  NEPHRITIS) 

Nephritis,  in  common  with  many  other  ailments  of  children,  may 
be  either  mild  or  severe.  It  may  be  so  severe  as  to  cause  death  in  a  few 
hours,  or  so  mild  as  to  pass  unrecognized.  In  cases  often  classed  as 
primary,  nephritis  probably  is  the  sequel  of  unrecognized  scarlet  fever. 
I  have  seen  but  three  apparently  primary  cases  in  young  infants  three 
and  four  months  of  age,  in  whom  no  previous  disease  had  existed. 
All  were  institution  children,  and  all  the  cases  came  to  autopsy. 

Etiology. — In  an  immense  majority  of  cases  acute  nephritis  occurs 
as  a  complication  of  the  acute  infectious  diseases.  Nephritis  is  more 
frequently  associated  with  scarlet  fever  than  with  any  other  ailment  of 
childhood,  I  have  observed  nephritis  complicating  scarlet  fever, 
diphtheria,  parotiditis,  measles,  malaria,  influenza,  variceUa,  general 
sepsis,  and  acute  intestinal  infection. 

Effects  of  Different  Toxic  Agents. — Acute  inflammation  of  the  kid- 
neys is  caused  by  chemical  or  bacterial  irritants.  In  the  course  of 
any  local  or  general  infection,  toxins  or  bacteria,  or  both,  are  excreted 
by  the  kidneys,  and  may  cause  degeneration  or  inflammation  of 
these  organs.  Thus  pneumococci  may  be  isolated  from  the  urine  in  the 
course  of  a  nephritis  complicating  pneumonia,  typhoid  bacilli  during 
typhoid  fever,   and  streptococci  during  any  streptococcal  infection. 


442  THE    PRACTICE    OF    PEDIATRICS 

The  bacteria  are  also  found  in  the  kidney  at  autopsy.  The  diphtheria 
toxin,  and  not  the  bacillus  itself,  is  the  cause  of  post-diphtheric 
nephritis. 

Suppurative  inflammation  of  the  kidney  may  be  of  hematogenous 
origin,  due  to  any  one  form  of  the  pyogenic  cocci,  or  it  may  be  caused 
by  an  ascending  inflammation  from  the  bladder,  ureter,  and  pelvis  of 
the  kidney.  The  latter  condition  is  a  pyelonephritis,  and  its  almost 
invariable  cause  is  B.  coli  communis. 

Pathology. — The  changes  which  occur  in  the  kidney  may  be  pre- 
dominantly exudative  or  productive  in  character,  and  may  effect  the 
parenchyma  most  severely,  or  be  fairly  well  limited  to  the  interstitial 
tissue. 

In  ordinary  acute  nephritis  of  the  parenchymatous  type  the  organ  is 
enlarged,  of  decreased  consistence,  and  on  section  presents  a  dull  gray 
cortex  the  capsule  of  which  strips  easily.  There  is  more  deeply  con- 
gested medulla.  Structural  markings  are  obscured,  although  occa- 
sionally the  glomeruli  stand  out  on  the  cut  surface  as  scattered  reddish 
spots.  Microscopically,  the  parenchyma  is  found  to  be  the  seat  of 
granular  degeneration  and  exfoliation,  so  that  the  tubules  have  become 
dilated  with  necrotic  cell-products,  casts,  and  free  blood-corpuscles,  the 
amount  of  blood  depending  on  the  degree  of  congestion  in  the  vessels 
of  the  glomeruli.  The  kidney  stroma  is  edematous  and  may  show 
considerable  cellular  infiltration  and  proliferation.  Proliferation  of  the 
cells  lining  the  capsule  of  Bowman  is  also  common. 

Shennan  states  that  the  degenerative  changes  in  the  kidney  depend 
on  the  nature  of  the  causative  toxin  and  its  concentration,  some  toxins 
producing  chiefly  catarrhal  changes,  while  others  cause  cell  necrosis. 
The  urine  under  the  conditions  described,  although  decreased  in  amount 
and  containing  albumin  and  casts,  may,  nevertheless,  be  of  low  specific 
gravity,  due  to  diminished  excretion  of  urea. 

In  acute  nephritis  of  the  interstitial  type,  which  is  much  less  frequent, 
the  urine  may  be  free  from  pus,  casts,  and  albumin.  More  often,  how- 
ever, this  condition  does  not  obtain,  as  the  nephritis  is  secondary  to  a 
general  pyemia  or  part  of  an  ascending  pyelonephritis,  in  which  case  the 
tubules  microscopically  show  evidences  of  marked  degeneration  in 
addition  to  the  more  apparent  process,  an  infiltration  of  the  connective 
tissue  with  polynuclear  cells. 

In  a  late  nephritis  of  the  interstitial  type  the  development  of 
fibrous  tissue  with  atrophic  changes  in  the  glomeruli  may  possibly 
render  the  diseased  organ  smaller  and  firmer  instead  of  larger  and 
softer  then  normal. 

In  the  typical  diseased  kidney  of  scarlet  fever  there  is  a  very  char- 
acteristic glomerular  nephritis,  marked  by  a  proliferation  of  the 
epithelial  and  endothelial  cells  lining  the  capsules  and  on  the  tufts,  and 
by  an  extensive  round-cell  infiltration  of  the  tissue  about  the  glomeruH. 
A  severe  attack  of  renal  congestion  during  the  febrile  period  of  scarlet 
fever  does  not  ordinarily  become  chronic;  but  a  glomerulonephritis, 
slow  in  onset  and  of  the  productive  type,  may  cause  death  from  acute 


ACUTE    PARENCHYMATOUS    NEPHRITIS  443 

suppression  of  urine  during  convalescence,  or  perhaps  terminate  in 
chronic  nephritis. 

Time  of  Development. — Nephritis  may  develop  at  any  time  during 
the  active  stage  of  scarlet  fever.  It  is  rare  before  the  third  week,  and 
it  may  be  delayed  for  several  weeks  after.  Cases  not  infrequently 
develop  after  the  sixth  week.  I  have  known  the  nephritis  to  appear 
as  late  as  three  months  after  the  acute  symptoms  of  the  primary 
disease  have  subsided.  The  severity  of  scarlet  fever  bears  but  httle 
relation  to  the  development  of  nephritis  or  the  time  of  such  develop- 
ment. In  consultation  practice  a  previously  undiagnosed  illness, 
with  rash  or  stomach  disturbance,  has  been  determined  as  having 
been  scarlet  fever  by  the  development  of  nephritis  at  a  considerably 
later  date. 

Symptoms. — The  disease  may  exist,  run  a  mild  course,  and  termi- 
nate favorably  without  symptoms.  That  this  occurs  in  many  in- 
stances is  beyond  doubt. 

Usually  the  first  symptom  noticed  is  a  slight  puffiness  (not  edema) 
about  the  eyes.  A  similar  puffiness  of  the  fingers  and  the  ankles  occurs, 
and  the  backs  of  the  hands,  as  well  as  the  ankles,  soon  become  edema- 
tous. The  skin  becomes  pale  and  of  peculiar  waxy  whiteness.  The 
patient  exhibits  loss  of  appetite  and  nausea,  and  sometimes  vomits. 
Mild  frontal  headache  is  a  frequent  symptom.  As  the  case  pro- 
gresses the  peculiar  pallor  increases,  the  face  becomes  very  much  swollen, 
the  eyes  almost  close,  and  the  legs  and  the  feet  increase  very  much  in 
size  and  have  a  cushion-like  appearance  and  consistence.  The  sub- 
cutaneous tissue  over  the  back  and  abdomen  becomes  infiltrated,  and 
the  whole  aspect  of  the  body  is  changed.  There  is  a  smoothing  out 
of  the  folds  and  angles,  giving  a  decidedly  rotund  appearance.  As  the 
result  of  such  a  general  edema  the  child  increases  very  much  in  weight. 
A  child  weighing  40  pounds  will  increase  in  weight  one-third.  1 
have  seen  an  increase  of  15  to  20  pounds  in  not  a  few  cases. 

In  children  one  would  invariably  look  for  the  more  active  symp- 
toms, headache,  vomiting,  and  prostration,  but  in  many  instances 
these  symptoms  are  not  prominent. 

Fever. — An  elevation  of  temperature  usually  exists  in  all  cases,  but 
it  is  not  necessarily  high.  Although  a  fever  of  103°  to  105°I.  is  of 
occasional  occurrence,  the  usual  temperature  range  is  from  100°  to 
103°F.  The  temperature,  as  a  rule,  is  not  of  long  duration  unless  the 
case  is  to  have  a  fatal  termination.  I  look  upon  a  high  continuous 
temperature  as  an  unfavorable  sign. 

The  Urine. — In  every  case  of  scarlet  fever — in  fact,  in  all  infectious 
diseases — the  urine  should  be  examined  daily,  as  recommended  under 
the  subject  of  management.  Time  and  again  1  have  known  cases  show- 
ing a  moderate  amount  of  albumin  and  casts,  with  a  few  blood-cells,  to 
clear  up  entirely  under  treatment.  If  these  cases  are  not  recognized 
and  properly  treated,  a  large  proportion  go  on  to  develop  the  more 
serious  characteristic  signs  of  the  disease. 

The  first  objective  sign  will  be  scantiness  of  the  excretion  of  urine. 


444  THE    PRACTICE    OF    PEDIATRICS 

The  urine  voided  will  be  reduced  from  a  total  quantity  of  30  to  40 
ounces  to  only  10  to  15  ounces.  Later  a  very  few  ounces  only  may  be 
excreted,  or  the  urine  may  be  completely  suppressed  (anuria). 

The  color  becomes  very  dark,  and  if  blood  is  present,  the  urine  will 
show  a  decidedly  smoky  appearance.  Blood  may  be  present  in  such 
large  amounts  as  to  give  the  appearance  of  pure  blood. 

Uremia. — In  very  severe  cases  uremic  convulsions  may  occur. 
Severe  headache  and  repeated  vomiting,  with  scanty  urine  and  de- 
ficient excretion  of  urea,  are  indications  that  uremia  exists. 

Convulsions. — The  convulsion  comes  on  suddenly  and  is  bilateral. 
It  may  last  but  a  few  minutes,  or  it  may  last  for  several  hours.  The 
child  may  die  in  convulsions. 

Fulminating  Cases. — A  form  of  acute  nephritis  which  deserves 
particular  attention  occurs  early  in  malignant  scarlet  fever.  The 
onset  is  very  abrupt.  But  little  urine  is  passed,  and  this  is  filled  with 
albumin,  casts,  and  blood. 

Illustrative  Case. — In.  a  recent  case  complete  suppression  occurred  without  pre- 
vious warning,  and  the  child  died  in  thirty-six  hours,  the  duration  of  the  entire 
illness  being  laut  seventy-two  hours.  There  was  no  edema.  The  child  became 
comatose,  and  died  from  the  uremia  and  the  intense  scarlatinal  poisoning. 

Duration. — The  duration  of  an  attack  depends  largely  upon  the 
severity.  Thus  I  have  had  cases  well  in  one  week,  and  others  in  which 
the  urine  was  not  free  from  albumin  and  casts  for  six  weeks  and  some- 
times longer.  In  case  of  apparent  recovery  I  do  not  look  upon  the 
patient  as  fully  recovered  until  twelve  months  have  elapsed.  I  never 
allow  a  child  who  has  had  well-marked  nephritis  to  pass  from  my 
observation  within  less  than  one  year.  A  peculiarity  of  nephritis  is 
its  tendency  to  return.  The  chronic  cases  which  we  see,  both  in 
private  and  in  hospital  work,  almost  invariably  give  a  history  of  two 
or  more  acute  attacks,  at  intervals  perhaps  of  several  months.  The 
second  and  subsequent  attacks  might  have  been  prevented  by  proper 
protection  and  care. 

It  may,  therefore,  be  put  down  as  a  fact  that  chronic  nephritis  in  a 
child  often  means  neglect,  as  much  on  the  part  of  the  family  as  on  the 
part  of  the  physician. 

Prognosis. — The  prognosis  of  severe  acute  nephritis  is  good  if 
proper  management  is  carried  out  from  the  beginning  of  the  illness 
until  at  least  one  year  has  elapsed.  The  prognosis  is  bad  in  even  a  mild 
case  if  it  is  neglected.  Nephritis  is  one  of  the  diseases  in  which  right 
management  is  most  essential,  even  in  very  mild  cases. 

Diagnosis.^ — ^That  nephritis  is  present  is  indicated  by  the  appear- 
ance of  swelling  about  the  eyes  and  ankles,  or  by  a  more  active  onset  of 
vomiting,  fever,  and  headache. 

Suspicion  in  any  given  case  may  be  easily  verified  by  a  urine 
examination. 

Examination  of  Urine. — If,  during  scarlet  fever  or  any  of  the  infec- 
tious diseases,  the  physician  takes  the  precaution  of  having  nitric  acid 
and  a  few  test-tubes  at  the  home  of  the  patient  so  that  the  urine  may  be 


ACUTE    PARENCHYMATOUS    NEPHRITIS  445 

tested  for  albumin  at  each  visit,  in  addition  to  a  reasonably  frequent 
microscopic  examination  at  his  office,  a  nephritis  may  be  detected 
before  the  more  active  clinical  signs  of  the  disease  appear;  and  thus, 
by  placing  the  patient  promptly  under  suitable  management,  usually 
but  little  trouble  will  be  experienced. 

Treatment. — The  treatment  of  nephritis,  reflecting  as  it  does  the 
present  methods  of  schools,  in  their  advocacy  of  forced,  indiscriminate 
water-drinking,  the  exclusive  milk  diet,  and  the  more  or  less  indis- 
criminate use  of  diuretic  drugs,  is  often  open  to  the  most  emphatic 
criticism.  Even  one  of  these  measures  is  capable  of,  and  has  been 
productive  of,  no  little  harm.  Too  great  emphasis  has  been  placed 
upon  forcing  the  kidneys  to  act,  and  too  little  upon  the  necessity  of 
relieving  them  of  the  work  for  which  they  are  temporarily  incapaci- 
tated. The  advocacy  of  drinking  large  amounts  of  water  when  the 
kidney  blood-vessels  are  distended,  the  tubules  are  obstructed,  and 
the  parenchyma  is  secreting  but  very  little,  does  nothing  but  harm. 
Under  such  conditions  heart  stimulants,  such  as  digitalis,  which 
forces  more  blood  into  the  kidneys,  necessarily  make  a  bad  matter 
worse. ' 

General  Management. — In  treating  nephritis  there  are  several  factors 
to  be  kept  in  mind.  Because  a  case  is  mild  it  should  never  be  given 
scant  attention.  Nephritis  in  a  child  may  be  most  insidious  in  its 
course.  The  mildest  case,  while  not  treated  in  all  respects  like  a  more 
severe  one,  should  be  given  every  possible  attention  relating  to  rest 
in  bed  and  diet;  for  through  neglect,  even  for  a  very  few  hours,  a  mild 
case  may  become  most  severe. 

A  child  with  nephritis  must  be  kept  in  bed  with  the  temperature  of 
the  room  at  about  70°F.  He  should  be  protected  from  drafts  of  cold 
air.  Silk,  a  mixture  of  silk  and  wool,  or  flannel  should  be  worn  next  to 
the  skin. 

Diet. — The  nutrition  of  the  patient  is  to  be  maintained  by  food 
which  will  not  add  to  the  existing  trouble.  We  are  told  that  nitrogen- 
ous food,  such  as  meats  and  eggs,  is  to  be  avoided  in  order  to  relieve 
the  kidneys  from  the  work  of  excretion  of  urea  and  creatinin ;  and  yet, 
often  we  are  advised  in  the  very  next  line  to  give  a  full  milk  diet, 
which,  in  the  case  of  a  child  from  five  to  ten  years  of  age,  means  from 
two  and  one-half  to  three  quarts  daily.  Milk,  it  will  be  remembered, 
contains  4  per  cent,  of  nitrogenous  food,  necessitating  that  large  amounts 
of  nitrogenous  waste  by-products  be  excreted  by  the  kidneys. 

In  order  to  maintain  the  nutrition  of  the  patient,  proteid  is  neces- 
sary, and  may  be  supplied  by  the  use  of  a  moderate  amount  of  milk. 
To  a  child  from  five  to  ten  years  of  age,  from  16  to  20  ounces  of  full 
milk  should  be  given  daily — never  more  than  20  ounces.  This  should 
be  diluted  with  equal  parts  of  cereal  gruel.  No.  1  or  2,  with  the 
addition  of  one  teaspoonful  of  sugar  (see  formulary,  p.  70),  and 
given  in  quantities  from* 6  to  10  ounces  at  four-hour  intervals.  The 
taste  of  the  food  may  be  changed  by  the  use  of  cereal  gruels  of  differ- 
ent kinds.     Zwieback  and  butter,  stale  bread  and  butter,  prune-juice, 


446  THE    PRACTICE    OF    PEDIATRICS 

simple  fruit  jellj^,  thin  apple-sauce,  and  orange-juice  may  be  given  in 
order  to  improve  the  digestion  and  add  variety  to  the  diet.  Inas- 
much as  milk  and  fruit  cannot  be  taken  simultaneously  by  many 
patients,  the  fruit  may  be  given  between  meals  or  with  a  plain  meal 
gruel,  and  thus  increase  the  nutritive  value  of  the  daily  ration.  Broths 
and  beef  extracts  are  not  to  be  given  because  of  their  creatinin  content. 

The  Salt-free  Diet. — The  value  of  a  salt-free  diet  in  nephritis  is  now 
very  generally  recognized.  The  rationale  underlying  this  treatment 
has  been  concisely  set  forth  by  L.  Miller,  who,  after  reviewing  the  work 
of  Widal,  Javal,  and  other  observers,  states  the  following  conclusions : 

"In  patients  with  moderately  severe  nephritis  associated  with 
edema  the  ingestion  of  large  amounts  of  sodium  chlorid  is  followed  by 
chlorid  retention.  The  patient  gains  in  weight,  the  edema  becomes 
more  marked,  the  albuminuria  increases,  and  symptoms  may  develop 
resembling  uremia. 

"In  patients  with  very  severe  nephritis,  and  especially  those  with 
uremia,  chlorid  retention  is  very  marked,  as  scarcely  any  of  the  extra 
chlorid  administered  is  eliminated. 

"In  individuals  with  apparently  healthy  kidneys,  following  the 
ingestion  of  sodium  chlorid  there  is  a  chlorid  retention  equal  to  that  of 
a  mild  nephritis.  The  individual  gains  in  weight,-  but  there  is  no 
visible  edema,  no  albuminuria,  and  no  uremic  symptoms." 

The  degree  to  which  defective  kidney  excretion  is  responsible  for  the 
edema  of  nephritis  is  still  in  doubt,  but  it  is  certain  that  exclusion  of 
common  salt  from  the  food,  including  even  such  substances  as  bread, 
is  frequently  followed  by  marked  improvement,  which  ceases  on  a 
return  to  the  salt-containing  diet. 

Bowel  Evacuation. — A  patient  with  nephritis,  no  matter  how  mild, 
should  have  two  bowel  evacuations  daily.  These  should  be  rather 
loose.  Ths  use  of  the  fruit-juices  may  be  sufficient  to  keep  the  bowels 
relaxed.  If  a  laxative  is  necessary  citrate  of  magnesia,  or,  for  very 
young  children  and  infants,  milk  of  magnesia,  may  be  given  in  such 
doses  and  at  such  intervals  as  may  be  necessary  to  produce  the  desired 
results.  The  patient  should  always  have  an  enema  at  bedtime  if  no 
passage  has  taken  place  during  the  preceding  twenty-four  hours. 

Bath. — A  warm  sponge-bath  should  be  administered  daily,  the  pa- 
tient being  sponged  and  dried  part  by  part  under  a  flannel  blanket. 

Treatment  of  Severe  "Cases. — When  there  is  fever  with  partial  sup- 
pression of  the  urine,  only  one-half  the  usual  quantity  being  passed, 
and  that  loaded  with  albumin,  blood,  and  casts,  with  perhaps  beginning 
edema,  colon  flushings  (p.  795)  with  a  normal  salt  solution  at  a  tem- 
perature of  110°F.  are  to  be  used.  The  flushings  have  the  effect  of 
increasing  the  functional  activity  of  the  kidneys.  For  a  child  from  five 
to  ten  years  of  age  one  pint  of  the  warm  saline  solution  may  be  thrown 
into  the  colon.  An  effort  should  be  made  to  have  the  child  retain  the 
fluid  by  resting  on  the  left  side  with  the  buttocks  elevated  on  a  pillow. 
For  young  children  from  eight  to  twelve  ounces  may  be  used.  Infants 
under  nine  months  may  retain  only  four  to  six  ounces.     The  flushings 


ACUTE    PARENCHYMATOUS    NEPHRITIS  447 

should  not  be  repeated  oftener  than  at  twelve-hour  intervals,  unless 
the  condition  is  urgent,  as  intolerance  of  the  parts  is  readily  brought 
about  by  too  frequent  manipulations. 

If  the  skin  is  hot  and  dry  and  the  temperature  tends  to  remain  above 
102°F.,  tincture  of  aconite  may  be  given  in  small  doses.  To  a  child 
three  years  of  age,  one-half  drop  may  be  given  at  two-hour  intervals. 
Older  children  may  be  given  one  drop  at  a  dose.  It  is  rarely  wise  to  in- 
crease the  amount  above  two  drops  at  two-hour  intervals  even  for 
children  above  ten  years  of  age.  Only  sufficient  aconite  should  be 
given  to  produce  a  slight  diaphoresis,  for  when  the  skin  is  kept  con- 
stantly moist,  the  blood-vessels  of  the  kidneys  are  relieved  of  the  tension 
to  which  they  have  been  subjected. 

In  the  severer  cases,  with  edema  or  anasarca,  in  which  but  two  or 
three  ounces  of  urine  are  passed  daily,  more  active  measures  will  be 
required.  In  these  urgent  cases  the  diet  should  consist  temporarily 
of  thin  gruels  of  barley,  granum,  or  rice  (No.  1),  with  sugar  added  to 
make  them  more  palatable,  and  diluted  fruit-juices  given  between 
the  feedings.  In  a  carbohydrate  diet  there  are  no  by-products  irri- 
tating to  the  kidney.  Water  should  be  given  scantily,  sufficient  fluids 
being  given  in  the  food.  Active  measures  to  increase  diaphoresis  and 
thus  relieve  the  kidneys  must  be  instituted.  The  best  method  of  do- 
ing this  is  by  the  use  of  hot  colon  flushings,  hot  packs,  hot  baths,  and 
hot  flaxseed  poultices.  In  these  severe  cases  the  use  of  digitalis  and 
alkaline  diuretics  does  an  immense  amount  of  harm.  Digitalis  drives 
more  blood  into  the  kidneys  and  thus  increases  the  congestion.  The 
alkaline  diuretics  disturb  the  stomach,  which  is  already  showing  signs 
of  food  intolerance.  Colon  flushings  (p.  795)  at  110°F.  are  to  be  used 
every  six  hours.  This  is  probably  one  of  the  most  valuable  means  we 
possess  for  relieving  the  congestion  of  the  kidney  and  inducing  a  flow 
of  urine. 

Local  Application  of  Heat. — Heat,  either  dry  or  moist,  should  be 
immediately  employed  in  order  to  stimulate  the  skin  to  vigorous  action. 
Dry  heat  and  moist  heat  each  has  its  advocates.  Keeping  the  child 
in  a  warm  bath  at  105°F.  for  a  few  minutes,  drying  rapidly,  and 
immediately  putting  him  into  bed,  surrounded  by  hot-water  bottles, 
will  usually  produce  diaphoresis.  A  thermometer  should  be  placed 
under  the  bed-clothing  so  that  excessive  heat  may  readily  be  detected. 
I  have  seen  pronounced  weakness  produced  by  the  use  of  excessive  heat. 
The  child  should  not  be  allowed  to  rest  in  a  temperature  higher  than 
120°F.,  and  heat  of  this  degree  should  not  be  maintained  over  ten 
minutes.  A  temperature  of  105°F.  or  110°F.  may  be  maintained  for 
an  hour  if  necessary.  If  the  pack  is  used,  it  may  be  repeated  once  in 
six  hours.  The  disadvantages  of  a  hot  bath  are  due  to  the  fact  that 
it  necessitates  considerable  handling,  which  to  some  patients  is  a  cause 
of  no  little  excitement.  In  such  cases  dry  heat  may  be  substituted, 
the  patient  being  warmly  clad  in  flannels,  while  hot-water  bottles  are 
placed  near  his  body.  This  may  be  sufficient  to  induce  perspiration. 
A  device  which  I  use  consists  of  a  funnel  attached  to  a  one-inch  brass 


448  THE    PRACTICE    OF   PEDIATRICS 

pipe,  which  is  bent  in  the  middle  to  a  right  angle  and  which  conducts 
the  warm  air  under  the  bed-clothing.  The  heat  is  generated  by  a  kero- 
sene lamp,  over  the  top  of  which  the  inverted  funnel  is  placed  at  a 
sufficient  distance  to  allow  combustion  to  take  place. 

In  some  cases  I  have  had  satisfactory  results  from  the  use  of  hot 
flaxseed  poultices  made  very  large,  6  or  10  inches  wide  and  2  inches 
thick,  and  sufficiently  long  to  entirely  envelop  the  abdomen.  These 
are  to  be  applied  as  hot  as  can  be  borne  at  about  twenty-minute  in- 
tervals for  one  hour,  and  repeated  again  in  three  hours.  This  inter- 
rupted use  of  the  poultices  has  been  continued  as  long  as  nine  days, 
with  most  marked  benefit,  both  in  private  and  hospital  cases. 

The  Murphy  drip  may  also  be  used,  but  it  has  not  proved  very  suc- 
cessful. The  pressure  of  the  tube  in  the  bowel  for  the  long  time  re- 
quired is  not  borne  well  by  children,  and  occasions  a  great  deal  of 
restlessness  and  irritability.  I  apply  this  means  only  in  extreme  con- 
ditions, in  which  the  child 's  state  is  such  that  he  is  not  annoyed. 

While  a  free  secretion  of  urine  is  desired  in  these  cases,  we  must  not 
be  content  with  that  alone.  Uremia  my  occur  even  while  the  normal 
amount  of  urine  is  being  passed.  A  quantitative  test  for  urea  should 
be  made  in  all  severe  cases  in  order  to  determine  the  amount  excreted. 
Normal  urine,  in  children,  contains  approximately  2  per  cent,  of  urea, 
which  in  health  occasionally  rises  to  3  per  cent.  Approximately  0.5 
gram  of  urea  is  excreted  per  kilogram  of  body-weight.  The  proportion 
in  children  is  relatively  higher.* 

Amount  of  Urea  Excreted  on  the  Basis  of  0.5  Gram  per  Kilogram 

in  24  hrs. 


,  /  Boys    9.29 4.645  gm. 

iyear        |  Qirls    8.24t 4.12    gm. 

3  years 


7  years 
10  years 
13  years 
16  years 


Boys  14.14 7.07    gm, 

Girls  13.60t... 6.80    gm. 

Boys  22.44 11.22    gm. 

Girls  21.78t 10.89    gm. 

Boys  30.22 15.11    gm. 

\  Girls  29.07t 14.535  gm. 

/  Boys  40.04 20.02    gm. 

\  Girls  41.36t 20.68    gm. 

/  Boys  56.09 28.045  gm. 

\  Girls  51.24t 25.62    gm. 


n  24  hrs. 
n  24  hrs. 
n  24  hrs. 
n  24  hrs. 
n  24  hrs. 
n  24  hrs. 
n  24  hrs. 
n  24  hrs. 
n  24  hrs. 
n  24  hrs. 
n  24  hrs. 


Treatment  of  Uremic  Convulsions. — Vomiting  is  one  of  the  first 
symptoms  of  uremia.  When  it  occurs,  all  food  should  be  temporarily 
withheld  from  the  stomach  and  nutrient  enemata  given.  Completely 
peptonized  skimmed  milk  is  our  best  means  of  nutrition,  from  4  to  12 
ounces  being  given  every  four  to  six  hours.  It  is  best  to  give  the  larger 
quantity  at  the  longer  interval, — every  six  hours  is  best, — as  the 
manipulations  with  the  tube  have  a  tendency  to  produce  intolerance 
on  the  part  of  the  gut.  The  tube  should  be  introduced  at  least  eight 
inches  into  the  bowel   and   the  solution  used   should   be  lukewarm. 

*  R.  Bradford,  in  Allbutt's  System  of  Medicine, 
t  Figures  of  Boas,  quoted  from  Holt. 


CHRONIC    DIFFUSE    NEPHRITIS  449 

Fluid  at  a  temperature  of  95°  or  100°F.  will  best  be  retained.  In 
addition  to  the  use  of  colon  flushings  and  external  heat  in  the  form 
of  the  flaxseed  poultices  referred  to,  uremic  convulsions  should  be 
controlled  with  chloroform  or  the  rectal  administration  of  the  bromids 
or  chloral.  To  a  child  under  three  years  of  age,  2  grains  of  chloral 
may  be  given  with  8  grains  of  bromid  of  soda.  After  the  third  year, 
3  grains  of  chloral  may  be  used  with  8  to  15  graing  of  bromid  of  soda. 
This  medicine  is  best  retained  when  given  in  at  least  4  ounces  of 
mucilage  of  acacia  or  skimmed  milk,  the  enema  being  repeated  in 
four  to  six  hours. 

When  heart  stimulants  are  required,  tincture  of  strophanthus  is 
usually  given — one  or  two  drops  at  two-hour  intervals  to  a  child 
under  three  years  of  age.  After  this  age  two  or  three  drops  may  be 
given.  Digitalis  is  sometimes  used  as  a  heart  stimulant  during  con- 
valescence, after  the  secretion  of  the  urine  has  been  established. 

Convalescence. — Convalescence  is  often  tedious  in  these  cases. 
The  child  should  not  be  allowed  to  be  out  of  bed  until  albumin  has 
disappeared  from  the  urine.  For  at  least  six  months  after  an  attack 
the  urine  should  be  examined  weekly.  Light-weight  woolens  should 
be  worn  next  to  the  skin  during  the  entire  year,  and  every  effort  made 
to  protect  the  patient  from  sudden  exposure  to  the  influence  of  cold  air. 
Upon  the  advent  of  any  subsequent  illness  with  fever,  even  though  it 
should  not  occur  for  a  year  or  two  afterward,  unusual  precautions  should 
be  taken  to  protect  the  child,  in  view  of  a  possible  rein  vol  vement  of  the 
kidneys,  with,  possibly,  a  resulting  chronic  nephritis.  Meat  and  eggs 
should  be  given  scantily  for  a  year  after  the  attack.  Exercise  calling 
for  more  than  ordinary  muscular  effort  should  not  be  allowed  for  at 
least  a  year  after  all  trace  of  the  nephritis  has  disappeared.  I  advise, 
when  possible,  that  the  winter  after  an  acute  attack  be  spent  in  a  warm 
climate,  such  as  that  of  Florida  or  Lower  California. 

CHRONIC  DIFFUSE  NEPHRITIS 

This  disease  is  rarely  seen  in  children  under  three  years  of  age.  I 
see  a  goodly  number  of  cases  every  year  in  children  from  the  fifth  to 
the  twelfth  year  of  age. 

Nephritis  of  this  type  is  almost  invariably  the  result  of  an  acute 
process  which  has  run  its  course  unrecognized  or  of  faulty  management 
following  acute  nephritis.  A  patient  who  came  under  my  care  three 
years  ago  with  chronic  nephritis  gave  a  history  of  having  had  three 
distinct  acute  attacks  during  the  previous  four  years,  with  intervals 
of  apparent  health.  The  urine  had  not  been  examined  during  these 
intervals  nor  had  she  had  the  advantages  of  proper  treatment.  Such  a 
history  is  quite  usual. 

Pathology. — In  chronic  parenchymatous  nephritis  (chronic  diffuse 

nephritis  without  marked  interstitial  changes)  the  kidney  is  enlarged, 

pale,  and  of  decreased  consistence.     The  capsule  strips  easily,  and  the 

cortex,  on  section,  is  found  to  be  wider  than  normal,  and  frequently 

29 


450  THE  PRACTICE  OF  PEDIATRICS 

of  a  light  yellowish  hue.  The  most  pronounced  microscopic  changes 
are  those  found  in  the  tubules,  the  epithelium  of  which  undergoes  a 
variable  amount  of  granular  and  fatty  degeneration  and  exfoliation. 
The  glomeruU  also  may  show  hyahne  changes,  swelling,  and  cellular 
prohferation  and  desquamation.  In  some  cases  the  disease  is  pre- 
dominantly a  chronic  glomerular  nephritis.  Interstitial  changes  are 
not,  as  a  rule,  important.  The  urine  may  be  cloudy,  is  usually  of  in- 
creased specific  gravity,  and  contains  albumin  in  variable  amount, 
leukocytes,  epithelial  cells  of  renal  origin,  hyaline  and  granular  casts, 
and  occasionally  red  corpuscles. 

Symptoms. — Chronic  nephritis  rarely  develops  insidiously  as  in 
the  adult.  Usually  it  is  a  continuation  of  the  second,  third,  or  fourth 
acute  exacerbation.  Instead  of  subsiding,  the  edema  and  the  pallor 
remain  pronounced,  and  the  abnormal  urinary  findings  persist. 

Anemia  is  always  present,  and,  as  the  condition  progresses,  digest- 
ive disturbances  become  manifest.  The  appetite  is  usually  indiffer- 
ent, and  commonly  there  is  vomiting.  Other  symptoms  are  marked 
edema  and  drowsiness.  The  progress  of  the  disease  is  variable.  There 
are  periods  when  recovery  seems  at  hand,  and  then  all  the  symptoms 
return  in  an  aggravated  form.  Ascites  is  usually  present  in  the  ad- 
vanced cases.  Effusion  into  the  pleural  cavity  and  into  the  pericar- 
dium may  be  looked  for.  Pulmonary  edema  is  a  constant  symptom 
a  few  days  or  hours  before  a  fatal  termination,  if  uremic  convulsions 
are  delayed. 

Prognosis. — The  patients  are  always  the  subjects  of  much  solici- 
tude. My  results  have  not  been  brilliant.  In  some  of  my  cases  the 
illness  began  after  an  infectious  disease,  usually  scarlet  fever,  and  ran 
a  slowly  progressive  course,  which  under  the  best  of  management  de- 
fied every  effort,  terminating  fatally  in  three  months  to  a  year.  In 
other  cases  improvement  occurred,  casts  and  albumin  disappeared 
from  the  urine,  and  the  child  was  apparently  well. 

Exacerbation.— 'Eyqh  in  favorable  cases,  however, — as  the  result  of 
exposure,  some  intercurrent  disease,  or  some  unknown  cause, — an  ex- 
acerbation occurs,  and  the  attack  is  repeated,  usually  in  graver  form 
than  the  previous  one.  The  urine  becomes  scanty  and  loaded  with 
albumin  and  casts,  the  child  becomes  edematous  and  pale.  Treat- 
ment may  perhaps  relieve  the  condition,  but  this  attack  is  followed  by 
another  in  three  to  six  months,  after  an  interval  of  apparent  health. 

Illustrative  Cases. — In  one  girl  four  years  old  five  distinct  recurrences  took  place' 
before  death,  which  occurred  in  the  fifth  attack. 

A  girl  nine  years  old  gave  a  history  of  chronic  nephritis  lasting  two  years.  She 
made  a  complete  recovery — at  least  there  has  been  no  recurrence  in  seven  years. 

A  boy  aged  four  remained  well  for  two  years  after  an  illness  covering  six  months. 
After  this  period  he  passed  from  my  observation. 

Diagnosis. — The  diagnosis  is  confirmed  by  repeated  urine  examina- 
tions. Albumin  and  casts  may  be  present  for  a  considerable  period 
without  other  signs  than  anemia.  The  anemia,  with  puffiness  about 
the  eyes  and  swelling  of  the  feet  and  ankles,  is  a  most  suggestive  sign. 


CHRONIC    DIFFUSE    NEPHRITIS 


451 


Treatment. — The  management  of  chronic  diffuse  nephritis  of  only 
moderately  severe  type  is  to  be  considered  with  respect  to  fom*  factors: 
diet,  baths,  exercise,  and  climate. 

If  the  patient  is  confined  to  bed,  the  diet  should  be  the  same  as 
suggested  under  Acute  Nephritis.  The  food  should  be  largely  salt- 
free.  Twenty  ounces  of  milk  may  be  given  daily.  If  the  child  is  up 
and  about,  meat  may  be  given  once  every  second  day.  Eggs  should 
be  excluded.  In  other  respects  the  diet  should  be  simple,  as  outlined 
for  well  children  (p.  105),  this  being  ample  for  nutrition. 


Fig.  55. — Chronic    nephritis    before 
Edebohls  operation. 


Fig. 


56. — Same  case  as  Fig.  55  after 
Edebohls  operation. 


The  child  should  receive  one  warm  bath — 95°  to  100°r. — daily, 
followed  by  brisk  friction  with  a  dry  towel. 

An  outdoor  life  is  of  decided  advantage.  Exertion,  however, 
should  not  be  allowed  to  the  point  of  fatigue.  Contests  or  stress  of 
any  kind,  mental  or  physical,  should  not  be  permitted. 

If  possible,  the  child  should  spend  the  colder  months  in  a  climate 
which  is  not  subject  to  sudden  or  wide  variations  in  temperature.  The 
climate  furnished  by  Florida  or  Lower  Cahfornia  is  advocated  when 
the  parents  are  financially  able  to  give  the  patient  this  benefit.  If, 
however,  the  patient  must  be  kept  iri  his  home,  which  does  not  offer 
the  advantages  of  an  equable  climate,  great  care  should  be  exercised 
in  preventing  sudden  chilling  of  the  skin  surface.  Woolens  should  be 
worn  next  to  the  skin  at  all  seasons  of  the  year.     Frequent  examina- 


452  THE    PRACTICE    OF    PEDIATRICS 

tions  of  the  urine  should  be  made,  not  only  for  albumin  and  casts,  but 
for  urea  as  well.  Sudden  attacks  of  uremia  may  occur  even  while  the 
patient  is  passing  an  excessive  amount  of  urine. 

The  management  of  suppression  and  anasarca  is  very  much  the 
same  as  described  for  these  conditions  occurring  in  acute  nephritis 
(p.  441). 

Diuretics  with  which  the  physician  is  famiUar  and  in  which  he  has 
faith,  may,  be  given  well  diluted,  so  as  not  to  disturb  the  stomach. 
In  the  severe  forms  of  chronic  diffuse  nephritis  I  have  yet  to  see  a 
diuretic  of  the  slightest  value. 

Illustrative  Case. — A  three-year-old  girl,  a  patient  in  the  Babies'  Hospital  in 
my  service,  presented  the  typical  picture  of  advanced  chronic  nephritis  (see  Fig. 
55).  The  usual  treatment  with  calomel,  salines,  colonic  flushings,  and  hot  packs 
and  diuretics  failed  to  make  any  impression.  The  urine  presented  the  usual 
changes  and  was  very  scanty.  After  two  weeks  of  unavailing  treatment,  during 
which  period  the  cliild  became  constantly  worse,  the  Edebohls  operation  of 
decapsulation  of  the  kidney  was  performed  by  Dr.  William  A.  Downes,  of  New 
York  City.  The  kidney  secretion  gradually  increased — the  urine  showing  but  a 
trace  of  albumin  two  weeks  after  the  operation.  The  thirteenth  day  following  the 
operation  the  child  had  lost  16)-^  pounds  in  weight  and  presented  the  appearance 
seen  in  Fig.  56.  There  was  an  interval  of  two  weeks  between  the  time  of  taking 
the  two  photographs. 

During  convalescence  from  the  operation,  however,  the  child  developed  a  very 
severe  colitis,  from  which  she  died  six  weeks  after  the  operation.  I  look  upon  this 
case  as  a  remarkable  demonstration  of  temporary  value,  at  least,  of  decapsulation 
of  the  kidney.  Unfortunately,  the  intercurrent  colitis  terminated  life  before  the 
permanent  effects  could  be  determined. 

CHRONIC  INTERSTITIAL  NEPHRITIS 

Chronic  interstitial  nephritis  is  a  very  rare  condition  in  children. 

Etiology. — The  etiology  is  obscure.  A  persistent  toxemia  from  in- 
testinal sources  is  the  most  logical  explanation. 

Syphilis,  alcoholism,  and  the  infectious  diseases  have  all  been  looked 
upon  by  different  authors  as  possible  etiologic  agencies. 

Symptoms. — A  wide  range  of  symptoms  is  put  down  by  authors. 
As  my  personal  experience  has  been  so  meager,  I  can  do  no  better 
than  recite  the  symptomatology  of  a  case  coming  under  my  observation. 

Illustrative  Case. — This  boy  evidently  had  suffered  from  the  disease  for  three  or 
four  years.  There  was  a  history  of  chronic  polyuria,  thirst,  and  enuresis.  He  v/as 
very  small,  very  thin,  and  anemic.  He  was  habitually  tired  and  listless.  The  skin 
was  dry  and  rough  and  appeared  to  be  pigmented  in  spots.  There  was  no  sugges- 
tion of  dropsy,  and  the  boy  had  never  been  known  to  perspire.  He  passed  from  60 
to  90  ounces  of  urine  daily.  The  specific  gravity  was  low.  The  one  specimen  ex- 
amined by  me  showed  a  specific  gravity  of  1002,  no  albumin  and  no  casts.  Death 
resulted  from  exhaustion  and  uremia. 

Treatment. — The  management  of  these  cases  is  symptomatic. 

ORTHOSTATIC  ALBUMINURIA 

Albuminuria  occurring  only  during  the  hours  when  the  upright 
position  is  maintained  is  not  uncommon  in  male  children  after  the  age 
of  six  years.     Females  are  less  often  affected.     It  has  been  observed 


PYELOCYSTITIS    (PYELITIS)  453 

that  while  the  albuminuria  is  due  to  the  upright  position,  lordosis 
contributes  especially  to  its  occurrence. 

Symptoms. — Most  of  the  subjects  are  somewhat  anemic  and  thin 
and  suffer  in  greater  or  less  degree  from  digestive  impairment  and 
symptoms  of  mild  toxemia  such  as  headache  and  irritability.  Holt 
states  that  a  degree  of  lordosis  is  the  rule.  The  urine  excreted  while 
the  child  is  at  rest  in  the  recumbent  position  is  not  abnormal  but  that 
excreted  following  assumption  and  maintenance  of  the  erect  position 
contains  albumin  in  varying  amounts  ranging  as  high  as  50  per  cent, 
by  volume.  Hyaline  casts  are  occasionally  found.  The  substance 
giving  the  albumin  reaction  is  serum  albumin  plus  probably  chondroitin 
sulphuric  acid  (Holt)  which  is  capable  of  being  precipitated  by  acetic 
acid  in  the  cold. 

Prognosis. — Orthostatic  albuminuria  commonly  terminates  in  re- 
covery after  the  age  of  puberty.  Occasionally  the  affection  persists 
into  adult  life. 

Treatment. — The  principles  of  treatment  essential  in  cases  of 
ordinary  malnutrition  are  to  be  followed  rather  than  the  methods  ap- 
plicable to  cases  of  true  nephritis.  Defects  in  posture  should  be  reme- 
died by  light  exercises  and  if  necessary  by  mechanical  support.  In 
other  respects  the  treatment  is  mainly  that  of  associated  malnutrition, 
anemia  and  digestive  disorder. 

PYELOCYSTITIS  (PYELITIS) 

Pyelocystitis  is  an  infection  of  the  bladder  and  pelvis  of  the  kidney. 
The  bladder  is  probably  always  involved,  and  may  precede  or  follow 
the  infection  of  the  kidney. 

Sex. — It  is  a  disease  of  infancy  and  early  childhood,  and  occurs 
almost  uniformly  in  females.     I  have  seen  but  five  cases  in  males. 

In  a  case  which  was  seen  by  me  late  in  the  illness  a  pyelonephritis 
had  developed  which  caused  the  death  of  the  child.  The  process  had 
extended  from  the  pelvis  of  the  kidney  to  the  kidney  structure,  which 
showed  dozens  of  large  and  small  suppurating  foci. 

Age. — The  majority  of  the  patients  are  under  three  years  of  age. 
Pyelitis  may,  however,  occur  at  any  age.  My  youngest  patient  was 
three  months  of  age,  the  oldest,  ten  years.  It  is  comparatively  rare 
after  the  fifth  year.  Its  occurrence  in  female  adults  does  not  concern 
us,  excepting  that  it  is  the  belief  of  not  a  few  internists  that  the  disease 
of  childhood  is  carried  over  to  adult  life. 

Etiology. — The  infection,  in  the  great  majority  of  cases,  is  due  to 
the  colon  bacillus.  Any  of  the  pyogenic  bacteria,  however,  which  gain 
entrance  to  the  bladder  and  pass  through  the  ureter  to  the  pelvis  of  the 
kidney  may  cause  the  disease.  Thus  the  staphylococcus,  the  strepto- 
coccus, the  gonococcus,  or  the  typhoid  bacillus  may  be  the  cause.  In 
one  of  my  cases  infection  was  due  to  the  typhoid  bacillus;  in  another, 
to  the  staphylococcus.  I  have  now  seen  a  large  number  of  cases  of 
pyelitis,  and  with  the  exception  of  the  one  case  of  typhoid  bacillus  in- 


454 


THE    PRACTICE    OF    PEDIATRICS 


fection,  they  were  all  either  preceded  by  an  acute  intestinal  disturb- 
ance, or  occurred  independently  of  any  illness.  The  facility  with 
which  the  infection  takes  place  in  girls  explains  its  frequency  in  the 
female  sex. 

I  have  observed  two  cases  in  which  there  was  a  bacteriuria, — a 
colon  bacillus  infection  without  demonstrable  pus, — but  with  the  usual 
chnical  signs  of  pyogenic  infection. 

Symptoms. — Pyelocystitis  is  a  disease  the  chief  symptom  of  which 
is  sudden  elevation  of  temperature.  That  children  may  have  the  dis- 
ease without  fever  cannot  be  disputed.  With  or  without  some  slight 
intestinal  disturbance  there  is  a  sudden  rise  in  temperature  from  102°  to 
105°F.  The  rise  is  usually  to  the  higher  point,  and  is  rarely  accom- 
panied by  a  chill.  Thomson  of  Edinburgh  believes  that  a  chill  in  an 
infant  is  always  due  to  a  pyelitis.  The  temperature  ranges  between 
101°  and  105°F.  for  three  or  more  days,  with  remissions  to  normal. 


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During  the  temperature  period  the  child  is  fretful  and  uncomfortable, 
but  not  particularly  prostrated.  After  the  fever  has  passed  the  patient 
may  appear  slightly  weak,  but  she  is  usually  bright  and  manifests  no 
great  physical  prostration;  in  fact,  there  may  be  no  sign  whatever  of 
illness  during  the  non-febrile  period.  The  disease  is  often  diagnosed 
as  indigestion  or  some  trivial  ailment,  and  is  forgotten  until  there  is 
again  a  rise  in  temperature,  which  runs  a  high,  irregular,  or  indifferent 
course  for  two  or  more  days,  and  then  again  subsides.  The  accom- 
panying chart  (Fig.  57)  represents  an  acute  case  of  short  duration. 
In  a  few  instances  the  duration  of  an  individual  attack  has  been  not 
more  than  ten  or  twelve  hours. 

There  is  usually  no  pain  in  these  cases,  and  no  unusual  frequency 
in  urination.     Very  infrequently  a  case  is  encountered  in  which  there 


PYELOCYSTITIS    (PYELITIS)  455 

are  bearing  down  and  straining  during  and  after  urination.  xA.bsence 
of  both  discomfort  and  frequency  of  urination  leads  one  to  believe 
that  cystitis  in  these  cases  is  probably  of  a  trivial  nature. 

The  symptom  above  all  others  of  value  in  this  disease  is  tempera- 
ture, and  when  we  have  distinct  temperature  periods  in  girls,  such  as 
are  shown  in  the  chart  (Fig.  57) ,  pyelitis  will  almost  surely  be  found  as 
the  cause. 

Diagnosis. — That  pyelitis  is  present  is  suggested  by  the  presence  of 
fever  not  readily  accounted  for,  in  a  female  infant  or  young  child. 
The  diagnosis  is  verified  by  the  finding  of  pus  in  the  urine.  Pus  is  not 
found  in  every  specimen  of  urine  voided.  Before  deciding  that  pus  is 
not  present  in  a  given  case,  at  least  three  specimens  should  be  secured  on 
different  days. 

For  absolutely  accurate  work  a  catheterized  specimen  of  urine 
should  be  secured,  particularly  if  the  urine  is  to  be  cultured.  This  is 
not  absolutely  necessary,  however,  in  a  routine  diagnosis.  If  the  child 
is  carefully  washed  before  urinating  and  the  urine  is  caught  in  a  sterile 
vessel,  there  will  not  be  sufficient  contamination  to  prevent  a  right 
conclusion. 

Differential  Diagnosis. — The  diseases  most  frequently  confused 
with  pyelocystitis  are  malaria,  typhoid  fever,  and  acute  intestinal  in- 
fection. The  distinct  temperature  periods  and  remissions,  with  days 
of  normal  temperature,  effectually  exclude  either  typhoid  or  malaria. 
The  continuation  of  the  temperature  periods,  after  the  intestinal  in- 
toxication is  reheved,  effectually  excludes  the  intestine  as  the  source 
of  the  fever.  Repeated  urine  examinations  confirm  or  disprove  the 
presence  of  pyelitis.  In  doubtful  cases  the  catheterized  specimen  of 
the  urine  should  be  cultured. 

Duration. — The  duration  is  variable,  and  appears  to  depend  more 
upon  the  time  the  disease  has  existed  unrecognized  than  upon  the 
nature  of  the  infection. 

A  patient  in  whom  the  condition  is  discovered  early  usually  re- 
sponds promptly,  and  perhaps  does  not  have  a  second  fever  period. 
Others  in  whom  the  disease  has  existed  for  several  weeks  undiagnosed 
may  require  several  months  of  treatment.  It  is  not  at  aU  unusual  for 
a  case  to  continue  over  two  or  three  months.  In  one  case  the  disease 
reappeared  after  an  absence  of  fever  and  pyuria  for  three  months.  In 
another  case  the  disease  reappeared  after  six  months  and  in  another 
after  eleven  months.  Whether  these  cases  represent  a  continuation 
of  the  old  process,  or  reinfection,  it  is  impossible  to  say.  I  am  inclined 
to  take  the  latter  view.  A  case  should  not  be  pronounced  cured  under 
six  months,  even  though  there  is  no  return  of  the  fever.  The  urine, 
during  this  time,  should  be  frequently  examined  for  pus. 

Treatment. — The  readiness  with  which  pyelitis  responds  to  treat- 
ment depends  considerably  upon  the  duration  of  the  infection.  The 
method  of  treatment  which  has  proven  most  satisfactory  is  as  follows: 
As  soon  as  the  diagnosis  is  positive,  from  GO  to  90  grains  of  citrate  of 
potash    are    given   daily    in    10-grain   doses  at    two-hour    intervals. 


456  THE    PRACTICE    OF    PEDIATRICS 

Suffioient  is  given  to  produce  alkaline  urine.  At  the  end  of  ten  days, 
the  potash  is  discontinued  and  urotropin  given,  usually  from  16  to  24 
grains  daily;  again  at  the  end  of  ten  days  the  potash  is  resumed.  This 
procedure  is  repeated,  alternating  the  two  drugs  until  the  urine  is  free 
frum  pus.     The  urotropin  is  effective  only  when  the  urine  is  acid. 

The  difficulty  that  I  have  experienced  has  been  to  obtain  sterile 
urine.  The  fever  is  usually  readily  controlled,  but  pus  and  bacteria 
remain  in  the  urine  over  long  periods. 

Time  Required  for  a  Cure.^ — The  urine  should  be  free  from  pus  for 
a  period  of  at  least  six  months  before  a  case  may  be  pronounced  well. 

Vaccine  Treatment. — The  use  of  vaccines  has  not  been  followed  by 
brilliant  results. 

The  application  of  this  method  of  treatment  to  urinary  infections 
in  children  should,  therefore,  at  present  be  limited  to  rare  cases  of  gono- 
coccus  or  staphylococcus  origin,  and  to  the  very  small  group  remaining, 
which  do  not  respond  to  medicinal  measures.  In  persistent  chronic 
colon  cases  vaccine  may  be  given  a  trial. 

I  have  used  both  autogenous  and  stock  vaccines  in  the  colon  bacillus 
infections  and  have  yet  to  be  impressed  with  any  great  value  of  the 
treatment.  I  have  employed  the  following  procedure  and  dosage 
without  appreciable  improvement.  Fourteen  injections  were  given 
with  one  week  intervening  as  follows:— 10,000,000;  20,000,000;  40,- 
000,000;  80,000,000;  200,000,000;  400,000,000;  500,000,000;  500,000,- 
000;  500,000,000;  500,000,000;  600,000,000;  500,000,000;  500,000,000; 
500,000,000. 

PRECOCIOUS  MENSTRUATION  AND  PRECOCIOUS  MATURITY 

Precocious  menstruation  is  a  physiological  anomaly  of  develop- 
ment (Morse).  The  usual  time  for  menstruation  to  begin  is  between 
the  ages  of  twelve  and  fifteen  years.  In  some  races  catamenia  begins 
normally  as  early  as  nine  or  ten  years. 

There  are  two  distinct  types  of  cases.  In  one  group  the  precocious 
menstruation  is  the  only  symptom,  while  in  the  other  there  is  preco- 
cious maturity.  The  early  menstruation  is  accompanied  by  the  ana- 
tomical changes  of  puberty. 

The  menstruation  in  the  former  type  of  children  usually  begins 
earlier  than  in  those  with  precocious  development.  The  average  time 
is  five  years  but  there  have  been  instances  reported  where  hemorrhages 
begin  at  birth.  The  periods  last  from  one  to  three  days  and  may  be 
regular  throughout  childhood.  This  is  not  usual,  however,  for  at  times 
for  a  year  or  more  there  may  be  no  signs  of  menstrual  flow.  The 
physical  and  mental  development  of  these  children  is  perfectly  normal. 

A  private  patient,  aged  nine  years,  strong  and  robust,  began  to  men- 
struate at  the  twenty-first  month;  very  irregular  at  first,  from  a  few 
weeks  to  two  or  three  months,  but  with  a  fair  degree  of  regularity 
during  the  past  six  years.  Pubic  hair  developed  at  the  sixth  year  and 
the  breasts  began  to  develop  at  the  same  time.     To  all  outward  appear- 


CYSTITIS  457 

ance  she  is  a  perfectly  normal  child,  with  no  signs  of  early  sexual 
development. 

In  the  second  group  we  are  dealing  with  a  profound  disturbance  of 
development  probably  due  to  some  derangement  of  the  ductless  glands. 
It  is  a  most  unusual  occurrence.  Lenz,  in  a  most  exhaustive  review  in 
1912,  was  only  able  to  collect  150  cases  from  the  literature.  Menstrua- 
tion in  these  children  usually  begins  early,  that  is,  during  the  first  two 
years  and  frequently  at  birth.  In  51  cases  collected  by  Morse,  36 
began  during  the  first  two  years.  These  patients  are  usually  large 
patients  at  birth,  they  have  large  breasts,  axillary  and  pubic  hair  and  a 
prominent  mons  veneris.  They  develop  very  rapidly  and  at  eight  or 
ten  years  may  present  the  full  maturity  of  the  adult.  The  menstrua- 
tion is  regular  and  preceded  early  in  life  by  various  feelings  of  dis- 
comfort, analogous  to  those  which  announce  the  periods  in  women. 
There  is  also  an  early  development  of  bone  as  shown  by  a:-ray. 

That  the  menstruation  in  these  children  is  accompanied  by  ovula- 
tion has  been  proved  by  autopsy  and  there  are  11  cases  in  the  litera- 
ture where  pregnancy  has  developed  in  childhood.  One  case  reported 
began  to  menstruate  at.  two  years,  became  pregnant  at  eight  years  and 
ceased  to  flow  at  twenty-five  years,  and  lived  to  be  seventy-five 
without  recurrence. 

Etiology. — The  etiology  of  this  condition  is  obscure  but  there  are 
facts  which  seem  to  indicate  that  it  is  a  disturbance  of  the  somatic 
glands.  There  have  been  instances  reported  where  the  abnormal  de- 
velopment has  ceased  and  even  retrogressed  after  the  removal  of  cystic 
tumors  of  the  ovary. 

These  children  should  be  kept  apart  from  other  children.  Their 
early  modesty  sense  should  be  respected. 

The  Bladder 
cystitis 

Cystitis  in  boys  is  very  unusual.  In  girls  it  occurs  frequently. 
It  is  not  of  infrequent  occurrence  in  hospital  work. 

Etiology. — The  most  common  bacteriologic  agent  in  the  causation 
of  cystitis  is  B.  coli  communis;  next  in  order  of  frequency  is  B.  proteus. 
The  presence  of  these  intestinal  bacteria  is  explained  by  the  fact  that 
intestinal  disease  usually  precedes  cystitis  in  children. 

Streptococci  and  staphylococci  have  been  found  in  the  urine  in 
cystitis.  Gonorrheal  cystitis  in  children  is  extremely  rare,  and  tuber- 
culous inflammation  of  the  bladder  is  uncommon,  even  in  older  children. 

Symptoms. — Frequent  calls  for  urination  constitute  the  most  usual 
symptom;  so  urgent  is  the  desire  to  void  the  urine  that  the  child  may 
be  unable  to  reach  in  time  a  place  suitable  for  the  discharge.  Incon- 
tinence by  day  and  night  is  usual  in  children  with  only  a  mild  degree  of 
bladder  involvement.  There  is,  ordinarily,  but  little  pain  attending 
urination.  Sometimes  there  is  evidence  of  distress  at  the  completion 
of  the  act,  but  this  is  unusual.     Inability  voluntarily  to  control  the 


458  THE    PRACTICE    OF    PEDIATRICS 

urine  during  the  day,  extending  over  a  considerable  period  of  time, 
points  to  bladder  involvement  due  either  to  the  presence  of  stone,  which 
is  most  unusual,  to  cystitis,  or  to  a  congenitally  small  bladder. 

Diagnosis. — Frequent  urination  due  to  transient  congestion  at 
the  neck  of  the  bladder  may  be  confused  with  cystitis.  Such  cases, 
however,  are  of  very  temporary  duration,  and  respond  readily  to  treat- 
ment, while  the  urine  examination  fails  to  show  evidence  of  bladder 
infection.  Pyelocystitis  or  pyelitis  may  be  confused  with  simple 
cystitis.  In  cystitis  without  involvement  of  the  kidneys  the  fever, 
which  may  signa;lize  an  infection  of  the  pelvis  of  the  kidney,  is  lacking. 
It  is  almost  impossible  to  say  positively  when  the  pelvis  becomes  in- 
volved and  when  a  cystitis  becomes  a  cystopyelitis,  for  a  cystopyelitis 
may  exist  for  weeks  without  an  elevation  of  the  temperature.  In  all 
cases  of  involvement  of  the  pelvis,  however,  there  probably  was  a  pre- 
ceding cystitis.  Temperature,  when  present,  is  a  determining  factor 
in  establishing  the  diagnosis  of  pyelitis;  further,  when  there  is  pyelitis, 
epithelium  from  the  pelvis  of  the  kidney  is  in  evidence  in  the  urine. 

Treatment. — The  treatment  consists  largely  in  the  use  of  internal 
medication.  Most  cases  respond  promptly.  Now  and  then  a  chronic 
case  is  seen  which  proves  most  obstinate.  A  case  of  this  nature  was 
observed  at  the  out-patient  service  at  the  Babies'  Hospital.  The 
patient,  a  girl,  came  with  a  cystitis  well  established.  Large  quantities 
of  pus  were  present  in  every  specimen  of  the  urine  examined.  In  this 
case  six  months'  treatment  with  bladder-washings  and  medication  was 
required  before  the  patient  could  be  considered  improved.  She  then 
developed  poliomyelitis  and  passed  from  observation. 

Irrigation  of  the  bladder  may  be  attempted.  It  has  been  of  very 
little  service  in  my  hands.  Bladder-washing  is  carried  on  with  no  little 
difficulty  and  annoyance,  and  usually  with  unsatisfactory  results.  My 
best  results  have  been  in  the  use  of  urotropin  and  sodium  benzoate,  4 
to  6  grains  of  each,  3  times  daily.  The  frequent  urination  is  relieved, 
and  the  successive  examinations  of  the  urine  show  a  gradual  disappear- 
ance of  the  pus. 

VESICAL  CALCULUS  (STONE  IN  THE  BLADDER) 

Stone  in  the  bladder  is  rarely  seen  in  children  under  ten  years  of  age. 
Four  cases  only  have  come  under  my  observation.  The  patients  were 
boys  aged  respectively  three,  four  and  one-half,  five,  and  seven  years. 
In  each  case  there  was  cystitis,  with  frequent  and  sometimes  impeded 
and  painful  urination. 

The  management  is  entirely  surgical. 

EXSTROPHY  OF  THE  BLADDER 

Exstrophy  or  eversion  of  the  bladder  is  a  rare  deformity,  affecting, 
in  most  instances,  the  male  sex.  This  condition  is  due  to  a  defect  in 
the  anterior  wall  of  the  bladder  and  to  failure  of  development  in  the 
abdominal  wall.     Through  the  existing  hiatus  the  posterior  portion  of 


BALANITIS  459 

the  bladder  protrudes  as  a  mass  covered  by  reddish  mucous  membrane, 
on  the  surface  of  which  the  urine  from  the  ureteral  orifices  is  discharged. 
Other  malformations  usually  exist,  of  which  the  most  important  are 
non-union  of  the  pubic  bones,  absence  of  the  penis  or  epispadias,  ab- 
sence or  non-descent  of  the  testis,  and  hernia.  In  the  female  the  em- 
bryonic cloaca  representing  bladder,  vagina,  and  rectum  may  persist. 
A  determination  of  the  sex  of  the  patient  is  occasionally  difficult. 

The  condition  is  most  pitiable.  The  constantly  discharging  urine 
makes  cleanliness  impossible,  and  the  odor  of  decomposing  urine  is 
always  present.  No  means  have  been  devised  for  a  satisfactory  collec- 
tion of  the  urine.  My  own  cases  have  all  been  seen  in  hospitals.  In 
these  instances  abundant  cotton  in  a  large  pad  was  bound  on  the  parts 
and  frequently  changed.  The  skin  surface  round  the  exstrophy  should 
be  protected  with  U.S. P.  zinc  ointment,  to  which  10  per  cent,  of  white 
wax  is  added  and  applied  on  linen.  This  makes  a  fairly  satisfactory 
water-proof  dressing  and  prevents  the  distressing  excoriation  of  the 
skin. 

Operation. — The  operation  for  deflecting  the  ureters  to  the  sigmoid 
or  rectum,  while  rarely  successful,  should  be  attempted. 

After  the  ureters  are  successfully  placed,  there  is  always  the  danger 
of  a  pyelitis.  Cases  are  recorded,  however,  in  which  the  results  of  the 
operation  have  been  most  satisfactory.  I  know  of  one  such  instance. 
In  this  case  the  readiness  with  which  the  rectum  assumed  the  bladder 
function  was  as  surprising  as  it  was  gratifying  to  the  patient.  The 
rectum  holds  the  urine  from  three  to  six  hours  without  inconvenience. 

Various  plastic  operations  have  been  advised,  the  object  being  to 
secure  a  bladder  orifice  to  which  some  portable  urinal  may  be  applied. 

The  Male  Genitals 

Practically  every  male  child  is  born  with  an  adherent  prepuce  and 
with  more  or  less  constriction  at  the  preputial  outlet.  The  penis  is  to 
be  considered  normal  only  when  the  foreskin  can  easily  be  retracted, 
laying  bare  the  glans. 

The  adhesions  and  constrictions  may  be  relieved  by  moderately 
stretching  the  foreskin  and  breaking  up  the  adhesions  with  a  fine  blunt 
probe,  after  which  the  glans  should  be  cleansed,  oiled,  and  the  foreskin 
drawn  forward  over  it.  The  cleansing  of  the  parts  with  Castile  soap 
and  warm  water,  which  necessitates  a  retraction  of  the  foreskin,  should 
be  practised  at  least  every  second  day  on  the  uncircumcised.  This  not 
only  keeps  the  parts  clean,  but  prevents  the  later  formation  of  adhe- 
sions and  a  possible  phimosis. 

Circumcision  should  be  performed  upon  every  male  child.  The 
operation  does  away  for  all  time  with  the  necessity  of  manipulation  of 
the  parts.     (See  p.  461.) 

BALANITIS 

Balanitis  is  a  swelling  and  inflammation  of  the  foreskin  due  to  a  local 
infection.     Unskilled  manipulation  in  stretching  the  prepuce  readily 


460  THE    PRACTICE    OF    PEDIATRICS 

produces  a  laceration,  opening  up  a  means  of  entrance  for  bacteria. 
In  severe  cases  the  parts  first  siiow  congestion  and  ttien  edema.  I 
have  seen  patients  with  long  foreskins  which  were  twisted  and  swollen 
to  a  size  three  or  four  times  that  of  the  penis.  In  advanced  cases  there 
will  be  suppuration  beneath  the  foreskin,  with  a  purulent  discharge 
from  the  orifice. 

Treatment. — If  the  case  is  seen  early,  wrapping  the  parts  in  gauze 
or  old  linen,  which  is  saturated  with  an  ice-cold  solution  of  bichlorid  of 
mercury  1  :  10,000  and  changed  every  half-hour,  will  usually  be  effec- 
tive. If  there  is  much  edema,  puncturing  in  several  places,  after  dis- 
infection, should  precede  the  wet  dressing.  If  there  is  a  purulent  dis- 
charge, the  sac  should  be  gently  syringed  at  least  twice  daily  with  a  3 
per  cent,  solution  of  hydrogen  peroxid,  diluted  one-half  with  water. 

When  the  suppuration  has  ceased,  with  a  return  to  normal  of  the 
parts  involved,  circumcision  should  be  done.  Operation  during  the 
acute  stage,  particularly  with  suppuration  present,  should  be  avoided 
unless  the  condition  is  very  urgent. 

PHIMOSIS 

Phimosis  consists  of  a  constriction  or  narrowing  of  the  preputial 
orifice,  sometimes  to  a  pin-point.  In  cases  where  the  foreskin  is  tightly 
bound  to  the  glands  by  adhesions  the  urine  may  be  emitted  in  drops; 
in  other  cases  the  prepuce  "  balloons  out "  during  urination  and  the  urine 
dribbles  away.  The  opening  may  be  sufficiently  large  to  show  under 
pressure  the  margin  of  the  urethral  opening,  in  which  instance  urination 
will  be  but  little  interfered  with. 

Phimosis  may  be  productive  of  various  nervous  manifestations, 
such  as  restlessness  and  irritabihty.  It  may  be  a  cause  of  retention  of 
the  urine.  In  two  of  my  cases  convulsions  were  apparently  caused  by 
phimosis.  Both  children  had  repeated  convulsions  until  they  were 
circumcised.  Both  suffered  from  marked  phimosis,  with  retention  of 
smegma  and  irritation  of  the  prepuce. 

Treatment. — The  cases  in  which  urination  is  impeded  require 
prompt  relief.  This  can  be  furnished  temporarily  by  introducing  a 
small  probe  or  a  director  and  carefully  sHtting  the  skin  with  sharp- 
pointed  scissors  until  the  glans  is  reached.  The  child  should  be  care- 
fully held  by  an  attendant  during  the  operation  and  great  care  should 
be  exercised  in  introducing  the  director.  After  the  operation  a  wet 
dressing  of  bichlorid  of  mercury  1  :  10,000  or  a  saturated  solution  of 
boric  acid  should  be  applied  to  the  wound  until  it  is  healed. 

Circumcision  should  never  be  long  delayed  in  cases  of  phimosis,  as 
it  furnishes  the  only  satisfactory  means  of  rehef .  Stretching  is  very 
apt  to  be  followed  by  recontraction,  which  only  intensifies  the  original 
condition,  while  the  unavoidable  laceration  of  the  mucous  membrane 
may  open  a  favorable  field  for  infection.  In  hospital  and  out-patient 
work  examples  are  numerous  of  the  harm  resulting  from  force  and  lack 
of  cleanhness  in  the  management  of  this  simple  and  easily  remedied 
condition. 


CIRCUMCISION  461 


PARAPHIMOSIS 


Paraphimosis  is  produced  by  the  retraction  of  a  tight  foreskin, 
which  later  becomes  so  contracted  behind  the  corona  as  to  prevent  the 
return  venous  flow.  As  a  result,  the  glans  becomes  greatly  swollen, 
deeply  congested,  and  edematous.  Urination  is  impossible.  The 
cases  which  I  have  seen  have  all  been  produced  by  the  mother  or  nurse 
in  an  attempt  to  retract  a  tight  foreskin  according  to  the  doctor's  direc- 
tions, after  he  had  stretched  the  prepuce  for  phimosis. 

Treatment. — If  the  retracted  skin  is  edematous,  it  may  be  punc- 
tured in  various  places  to  let  out  the  fluid.  Reduction  may  then  be 
attempted  by  taking  the  glans  between  the  thumb  and  the  first  and 
second  fingers  of  the  right  hand  and  making  gradual  pressure  backward 
against  the  thumb  and  first  finger  of  the  left  hand,  which  grasps  the 
penis  behind  the  prepuce.  If  the  reduction  cannot  be  eff"ected  in  this 
way,  as  occasionally  happens  if  the  case  is  of  long  standing  or  the  con- 
traction very  tight,  a  longitudinal  dorsal  incision  may  be  made  in  the 
skin  at  the  site  of  the  constriction.  After  the  reduction  a  wet  dress- 
ing of  a  saturated  solution  of  boric  acid  or  of  bichlorid  of  mercury 
1  :  10,000  should  be  kept  constantly  applied  to  the  parts  until  the 
swelling  has  subsided.     Then  circumcision  should  be  done. 

CIRCUMCISION 

Should  circumcision  be  practised  as  a  routine  measure?  There  is 
not  the  slightest  doubt  that  it  would  be  for  the  best  interest  of  every 
male  infant  if  he  were  circumcised.  The  operation  during  the  second 
week  of  life  is  a  trivial  matter.  In  one  out  of  every  five  male  infants 
circumcision  is  a  necessity  both  for  comfort  and  health.  In  marked 
degrees  of  phimosis  and  balanitis  circumcision  is  the  only  means  of 
relief. 

An  important  reason,  to  my  mind,  for  the  operation  as  a  routine 
measure,  is  that  it  settles  at  once  and  for  all  time  the  toilet  of  the  parts. 
The  penis  after  a  proper  circumcision  requires  no  further  manipulation 
on  the  part  of  the  nurse.  The  daily  retraction  of  the  foreskin  and  bath- 
ing of  the  parts  is  one  of  the  best  means  of  teaching  the  child  self-abuse. 
When  the  parts  are  not  attended  to  every  day  or  at  least  every  second 
day,  trouble  is  sure  to  follow  sooner  or  later,  in  the  form  of  adhesions 
and  inflammation  of  the  prepuce.  The  sensations  produced  by  the 
retraction  and  the  washing  are  not  unpleasant  and  the  child  soon  learns 
to  produce  them  himself,  through  leg  rubbing,  hand  pressure,  or  other 
means.  (See  Masturbation,  p.  479.)  Time  and  again,  after  having 
stretched  the  foreskin  and  broken  up  the  adhesions  because  operations 
were  refused,  I  have  had  the  case  return  in  a  few  weeks  with  the  adhe- 
sions and  the  contractions  as  bad  as  before,  the  nurse  or  mother,  timid 
or  neglectful,  having  failed  to  follow  my  directions.  In  case  of  phimo- 
sis it  may  require  considerable  skill  to  draw  the  foreskin  forward  after 
a  retraction.     It  is  not  always  safe  to  permit  the  attendants  to  attempt 


462  THE    PRACTICE    OF    PEDIATRICS 

it.     Not  a  few  times  I  have  seen  a  paraphimosis  (p.  461)  which  resulted 
from  an  inabihty  to  bring  forward  a  retracted  tight  foreskin. 

The  dorsal  sht,  so  often  practised  as  a  substitute  for  circumcision, 
is  to  be  used  only  as  a  temporary  expedient,  and  as  such  may  be  em- 
ployed whenever  circumcision  is  refused.  Never,  by  any  means,  does 
it  take  the  place  of  circumcision,  but  invariably  leaves  a  long,  redun- 
dant flap  of  skin,  which  easily  becomes  irritated,  causing  no  little  dis- 
comfort.    For  the  child,  it  also  is  a  great  temptation  to  manipulation. 

UNDESCENDED  TESTICLE 

During  the  latter  part  of  fetal  life  the  testicles  rest  in  the  scrotum. 
In  a  considerable  number  of  infants,  however,  one  or  both  testicles 
remain  in  the  canal  for  varying  periods,  the  descent  usually  taking 
place  during  the  first  year.  When  such  descent  does  not  occur,  the 
condition  may  be  considered  abnormal. 

In  small  children  usually  no  inconvenience  is  caused  by  the  malpo- 
sition of  the  organ.  I  have  repeatedly  found  one  or  both  testicles  in  the 
canal  in  children  up  to  the  sixth  year.  The  testicles  may  be  brought 
down,  but  disappear  as  soon  as  traction  is  removed.  In  older  boys, 
after  the  sixth  year,  the  condition  may  cause  trouble  because  of  the 
exposed  situation,  which  subjects  the  organs  to  possible  injury  in  play. 
Further,  if  they  are  left  in  the  abnormal  position,  the  question  of  pos- 
sible faulty  development  is  to  be  considered. 

It  is  important  not  to  confuse  this  condition  with  inguinal  hernia, 
hydrocele,  or  enlarged  inguinal  glands.  On  several  occasions  I  have 
known  a  truss  to  be  applied  to  an  undescended  testicle. 

Treatment. — While  I  have  known  boys  to  arrive  at  the  age  of  ten 
years  before  the  permanent  descent  occurred,  I  do  not  believe  waiting 
to  be  a  wise  routine  procedure.  If  the  testicle  is  freely  movable  and 
can  be  brought  into  the  scrotum,  it  is  safer  to  wait.  Nature  will  cure 
the  condition.  When  the  testicle  is  fixed  and  cannot  be  brought  into 
the  scrotum,  I  favor  early  operation — at  least,  not  later  than  the  sixth 
year.  In  these  cases  there  is  a  shortening  of  the  cord,  with  adhesions, 
which  prevents  the  descent. 

ORCHITIS 

Orchitis  is  a  most  unusual  disease  in  the  young.  I  have  seen  but 
two  cases,  both  complicating  mumps.  The  disease  may  also  be  due  to 
gonorrhea  and  to  trauma.  Tuberculous  orchitis  and  specific  orchitis 
occasionally  occur,  but  are  exceedingly  rare.  The  disease  may  be  ac- 
companied by  hydrocele.  When  epididymitis  is  present,  it  may  usu- 
ally be  traced  to  an  injury  or  to  an  existing  specific  urethritis. 

Pathology. — The  inflammation  in  the  epididymis  is  essentially 
catarrhal,  but  may  involve  the  interstitial  tissue  and  extend  to  the 
testis.     In  the  latter  organ  interstitial  changes  ordinarily  predominate. 

Symptoms. — The  process  is  seldom  attended  by  suppuration, 
though  the  inflammation  may  be  so  severe  as  to  cause  fever  and  other 


HYDROCELE 


463 


mild  constitutional  symptoms.  Local  manifestations  are  pain,  swelling, 
increased  heat,  slight  redness,  and  occasionally  some  edema  of  the 
scrotum. 

Treatment. — The  management  necessitates  rest  in  bed,  the  use  of 
saline  laxatives,  if  necessary,  and  support  of  the  inflamed  testicles  by  a 
wide  strip  of  adhesive  plaster  extending  from  thigh  to  thigh.  The 
application  of  warm  sedative  lotions  gives  much  relief  from  the  pain 
and  discomfort,  and  appears  to  shorten  the  duration  of  the  attack. 
Lead  and  opium  solution,  U.  S.  P.,  appHed  on  several  layers  of  gauze 
and  covered  with  cotton-wool,  should  be  renewed  every  three  hours. 
After  the  acute  symptoms  have  subsided  a  suspensory  bandage  should 
be  worn  for  several  months. 

HYDROCELE 

Hydrocele  is  an  excessive  accumulation  of  serum  in  the  peritoneal 
process  enveloping  the  testicle  and  epididymis.  In  children  the  con- 
dition is  usually  congenital,  although  it  may  be  unapparent  at  the  time 
of  birth.     Hydrocele  is  also  sometimes  caused  by  direct  injury. 


Nr^ 


Fig.  58. — Varieties  of  hydrocele :  a,  Congenital;  h,  infantile;  c,  funicular;  d,  encysted; 
e,  vaginal  (Da  Costa's  Modern  Surgery). 


The  affection  is  commonly  described  under  a  classification  of  the 
following  forms: 

(a)  Congenital  Hydrocele. — This  exists  when  the  funicular  process 
remains  patent,  and  is  frequently  accompanied  by  hernia.  The  tumor 
is  translucent,  elongated,  oval,  and  fluctuating,  and  is  reducible  under 
pressure  without  special  manipulation.  When  uncomplicated,  this 
swelling,  in  distinction  from  one  produced  by  hernia,  affords  only  a  dull 
percussion-note  and  fails  to  emit  a  gurgling  sound  on  reduction. 

(b)  Infantile  Hydrocele. — -This  type  is  distinguished  from  the  fore- 
going by  the  fact  that  the  funicular  process  in  the  upper  portion  of  the 
canal  is  closed.     The  fluid  mass  is  elongated  and  irreducible. 

(c)  Hydrocele  of  the  Cord  {Funicular  Hydrocele). — Simple  hydrocele 
of  the  cord  is  occasioned  by  the  closure  of  the  canal  in  its  lower  portion, 
while  the  funicular  process  above  remains  open.  Such  a  condition  is 
not  usual.  The  hydrocele  is  separate  from  the  scrotum  and  may  be 
associated  with  a  hernia. 


464  THE    PRACTICE    OF    PEDIATRICS 

More  frequently  the  canal  is  closed  at  both  its  upper  and  lower 
portions,  while  the  intervening  part  remains  open  and  is  distended  by 
an  accumulation  of  fluid. 

{d)  Encysted  hydrocele  of  the  cord  is  small,  translucent,  elastic,  and 
irreducible,  and  may  resemble  an  enlarged  lymph-gland  or  an  unde- 
scended testicle. 

(e)  Hydrocele  of  the  Tunica  Vaginalis,  with  Normal  Obliteration  of 
the  Funicular  Process. — "Common  vaginal  hydrocele"  is  firm,  tense, 
fluctuating,  and  irreducible.  Above  the  upper  limit  of  the  swelling  the 
cord  may  be  distinctly  felt. 

Treatment. — The  cure  of  hydrocele  in  infants  is  usually  spontane- 
ous. When  the  hydrocele  is  exceedingly  large,  aspiration  of  the  fluid 
under  rigid  aseptic  precautions  may  produce  a  permanent  good  result. 
In  cases  of  the  congenital  variety,  especially  those  associated  with 
hernia,  the  wearing  of  a  truss  is  important  as  a  means  of  assisting  in  the 
obliteration  of  the  funicular  process.  Injections  of  irritants  have  not 
been  necessary  in  my  cases.  Such  a  procedure  is  rarely  to  be  advised. 
I  have  seen  much  harm  done  by  punctures  and  injections  into  the  sac. 
Several  severe  cases  of  infection  of  the  parts  have  resulted  from  such 
procedures. 

GONORRHEA  IN  THE  MALE 

Specific  urethritis  in  male  infants  and  male  runabout  children  is  of 
rare  occurrence.  Eight  patients  under  four  years  of  age  have  come 
under  my  observation.  The  oldest  of  the  group,  aged  four  years, 
developed  a  stricture.  The  boy's  home  was  in  a  tenement,  and  he  had 
been  repeatedly  exposed  through  another  member  of  the  family,  who 
hoped  to  rid  herself  of  the  trouble  by  giving  it  to  the  boy.  The  other 
cases  occurred  in  a  children's  institution,  in  which  there  was  an  epi- 
demic of  specific  vaginitis. 

Treatment. — The  younger  boys  appear  to  respond  unusually  well 
to  an  irrigation  of  8  ounces  of  a  1:10,000  permanganate  of  potash 
solution  used  twice  daily. 

EPISPADIAS  AND  HYPOSPADIAS 

Both  of  these  abnormalities  are  congenital  defects  in  the  develop- 
ment of  the  penis,  characterized  by  imperfect  closure  of  the  urethral 
groove. 

In  most  cases  of  hypospadias  the  urethra  terminates  before  reach- 
ing the  base  of  the  glans.  In  epispadias,  which  is  much  less  common 
and  frequently  accompanies  exstrophy  of  the  bladder,  the  urethra  opens 
upon  the  dorsum  of  the  penis. 

The  simpler  forms  of  hypospadias  may  not  require  treatment,  par- 
ticularly if  the  urethral  opening  is  within  one  inch  of  the  normal  posi- 
tion of  the  meatus  (Wyeth).  When,  however,  the  malformations 
present  imperative  demands,  plastic  surgery  should  be  attempted. 


VULVOVAGINITIS    (sIMPLE)  465 

The  Female  Genitals 
vulvovaginitis  (simple) 

In  simple  vulvovaginitis  there  is  an  inflammation  of  the  mucous 
membrane  of  the  external  genitals,  with  a  shght  involvement  of  the 
vagina  in  its  lower  portion.  Further  extension  of  a  non-gonorrheal 
infection  to  the  uterus  and  tubes  probably  never  occurs. 

The  orifice  of  the  urethra  is  usually  reddened  and  inflamed. 

Etiology. — Ill-conditioned  children,  and  those  improperly  cared  for, 
furnish  the  majority  of  the  cases.  Now  and  then  an  apparently 
healthy  girl  will  develop  the  disease. 

Irritation  from  hand  manipulation  in  masturbation,  scratching  in 
eczema,  thread-worms,  and  constipation  may  all  bring  about  the  dis- 
charge. The  ailment  is  particularly  common  in  anemic  girls  whose 
vitality  is  habitually  below  normal. 

Symptoms. — There  is  moderate  itching  and  burning  of  the  parts 
and  a  secretion  of  rather  viscid  mucus.  In  some  cases  there  is  a  yellow, 
purulent  discharge,  resembling  that  of  gonorrheal  infection.  The  at- 
tention may  be  first  called  to  the  condition  because  of  a  staining  of  the 
clothing. 

Diagnosis. — The  condition  in  which  there  is  a  purulent  discharge 
requires  to  be  differentiated  from  gonorrheal  vaginitis.  This  is  very 
readily  done  through  bacteriologic  examination.  Without  the  aid  of 
the  microscope  differentiation  is  impossible. 

Prognosis. — The  prognosis  is  favorable.  Most  cases  recover  in  a 
few  weeks.  Resistance  to  treatment  and  chronicity  point  to  the 
presence  of  the  gonococcus. 

Treatment. — The  management  comprises  both  constitutional  and 
local  measures.  The  patient  should  be  given  a  daily  living  regime.  In 
these  cases  I  direct  when  the  child  shall  rise  in  the  morning,  when  she 
must  retire,  and  the  amount  of  rest  she  must  take  in  the  middle  of  the 
day.  In  this  way  the  output  of  energy  is  curtailed  and  waste  is  pre- 
vented. The  diet  is  so  arranged  as  to  give  the  patient  the  most  nutri- 
tion with  the  least  amount  of  digestive  activity.  Bitter  tonics,  cod- 
liver  oil,  and  iron  are  given  when  indicated.  As  much  out-of-door  life 
as  is  possible  is  encouraged.  In  short,  the  measures  advocated  in  the 
section  on  Delicate  Children  (p.  122)  are  applicable  here. 

Local  Measures. — Bathing  the  genitals  twice  a  day  with  warm  water 
and  Castile  soap,  followed  by  drying  with  absorbent  cotton,  prepares 
the  parts  for  an  absorbent  dusting-powder,  which  I  have  found  useful 
in  these  cases.     The  powder  used  is  of  the  following  composition : 

I^     Acldi  borici gr.  xxv 

Pulveris  amyli, 

Pulveris  zinci  oxidi aa^ss 

The  more  nearly  dry  the  inflamed  surfaces  are  kept,  the  more 
prompt  will  be  the  relief.     If  there  is  a  tendency  to  a  free  secretion  of 
mucus,  the  powder  may  be  applied  at  intervals  of  two  hours. 
30 


466  THE    PRACTICE    OF    PEDIATRICS 

A  convenient  means  of  applying  the  powder  is  with  an  insufflator, 
which  may  be  obtained  from  any  apothecary.  After  the  parts  are 
packed  with  the  powder,  a  dressing  of  old  linen  should  be  applied  and 
held  in  position  by  a  napkin  binder.  The  powder  should  be  reapplied 
often  enough  to  keep  the  parts  dry. 

I  have  known  many  cases  of  long  standing  to  respond  promptly  to 
the  above  management. 

GONORRHEAL  VULVOVAGINITIS  (SPECIFIC  VAGINITIS) 

Vaginitis  of  this  type  is  very  prevalent  among  the  congested  tene- 
ment population  in  all  large  cities.  Institutions  for  children,  if  they 
would  admit  the  patients,  could  always  supply  a  goodly  number  of 
cases. 

Etiology. — It  is  almost  impossible  to  keep  the  infection  out  of  in- 
stitutions, and  when  it  once  enters,  it  is  most  difficult  to  remove.  The 
disease  is  quite  distinct  from  venereal  disease  in  the  adult,  in  that  it  is 
contracted  through  indirect  means.  The  hands  of  the  mother  or  nurse, 
towels,  napkins,  the  thermometer,  may  all  furnish  a  means  for  trans- 
mission from  the  infected  to  the  healthy.  Day  nurseries,  most  neces- 
sary institutions,  are  often  unwittingly  distributing  agents  of  the 
gonococcus. 

At  the  New  York  Nursery  and  Child's  Hospital  I  have  labored  with 
this  disease  for  several  years  with  most  discouraging  results.  For  the 
reason  that  this  is  a  city  institution,  cases  with  vaginitis  must  be  ad- 
mitted and  the  institution  is  never  free  from  the  disease. 

In  private  work  I  have  known  of  several  cases  in  which  the  mother 
had  a  vaginal  discharge  of  a  suspicious  character.  In  two  cases  only 
the  disease  was  evidently  contracted  from  a  nursery  maid. 

Age. — No  age  is  exempt.  I  have  treated  infants  of  six  weeks  with 
the  infection.  In  older  girls,  after  the  tenth  year,  the  possibility  of 
infection  through  sexual  contact  may  be  considered,  but  even  at  this 
age  the  disease  is  most  unusual;  in  fact,  very  few  cases  are  seen  in 
children  after  the  eighth  year.  Very  young  females — under  three 
years  of  age — furnish  most  of  the  cases. 

A  resistance  to  the  special  forms  of  transmission  of  the  infection 
appears  to  be  acquired  with  advancing  years.  The  nursery  maids  in 
training  will  live  for  months  in  an  infected  ward,  working  with  the  pa- 
tient, and  not  become  infected,  whereas  if  a  healthy  female  infant  is 
placed  at  any  point  in  the  room,  she  will  become  infected  in  twelve  to 
thirty-six  hours;  practically  none  escape. 

A  female  child  six  months  of  age,  admitted  into  a  ward  maintained 
with  care  and  cleanliness,  containing  12  healthy  females  of  about  the 
same  age,  will  transmit  the  disease  to  one-half  of  the  number  in  two  or 
three  days. 

Symptoms. — Redness  of  the  vulva  may  be  apparent  without  dis- 
charge, or  there  may  be  a  mucous,  mucopurulent,  or  purulent  dis- 
charge. 


GONORRHEAL  VULVOVAGINITIS    (SPECIFIC  VAGINITIS)        467 

The  typical  discharge  is  thick,  viscid,  and  of  a  greenish-yellow 
color.  If  the  case  is  of  considerable  duration,  there  will  be  redness  and 
excoriation  of  both  mucous  and  skin  surfaces.  There  is  a  good  deal  of 
itching  and  discomfort.  In  older  children  micturition  may  be  painful. 
In  infants  no  discomfort  whatsoever  appears  to  be  occasioned  by  the 
disease. 

Extension  of  the  infection  through  the  uterus  to  the  tubes  and  pelvic 
cavity  is  of  most  unusual  occurrence.  I  have  seen  hundreds  of  these 
cases,  but  never  saw  a  complication  of  this  nature.  The  inflammation 
very  rarely  extends  beyond  the  cervix.  An  endocervicitis,  however,  is 
usually  present. 

Diagnosis. — The  presence  of  a  vulvovaginal  inflammation  with 
or  without  discharge  suggests  the  possibility  of  a  specific  vaginitis.  It 
is  a  mistake  to  suppose  that  there  must  be  a  visible  discharge  in  each 
case.  Time  and  again  smears  taken  from  a  vagina  that  is  simply 
moist  will  show  the  gonococcus. 

Microscopic  examination  of  the  secretion  must  decide  whether  or 
not  the  case  is  of  gonorrheal  origin. 

Prognosis. — A  guarded  prognosis  must  always  be  given.  Under 
the  care  of  a  trained  nurse  and  intelligent  mother  I  have  seen  cases 
recover  in  3  weeks,  but  usually  from  4  to  8  weeks  are  required  and  then 
the  management  suggested  below  must  be  followed  out  most  thoroughly. 
Vaginitis  among  female  patients  in  an  institution  is  much  more 
difficult  to  cure. 

Complications. — The  most  frequent  complications  are  conjunctivitis 
and  arthritis.  Conjunctivitis  is  the  one  most  commonly  encountered. 
Arthritis  (p.  656)  is  not  at  all  unusual.  I  have  seen  at  least  30  of  these 
cases. 

Prophylaxis. — This  disease  is  the  most  infectious  of  all  infectious 
diseases.  In  order  to  prevent  its  spread  in  a  family  in  which  there  are 
two  or  more  girls,  or  in  an  institution,  it  is  necessary  not  only  to  prevent 
personal  contact,  but  also  to  prevent  any  association  of  any  nature 
whatever,  and  this  includes  attendants,  clothing,  feeding  and  cooking 
utensils,  and  thermometers. 

It  seems  almost  impossible  for  nurses  in  attendance  in  vaginitis 
cases  not  to  convey  the  disease  to  well  female  infants.  At  the  New 
York  Nursery  and  Child's  Hospital  we  were  obhged  to  put  the  children 
in  a  separate  building,  with  nurses  who  cared  for  them  only.  Cheese- 
cloth napkins  were  used,  which  were  burned.  All  other  clothing  and 
bed-linen  was  boiled  before  being  taken  to  the  general  laundry. 

Treatment. — The  course  of  the  disease  is  most  protracted,  and  there 
is  no  specific  medication  which  we  may  use  either  locally  or  internally. 
I  have  treated  hundreds  of  these  cases  in  many  different  ways,  includ- 
ing the  use  of  solutions  of  bichlorid  of  mercury  and  of  permanganate  of 
potash  of  different  strengths.  I  have  used  the  various  silver  salts  in 
different  strengths  as  applications  to  the  parts.  I  have  learned,  in 
treating  a  vast  number  of  these  cases,  that  keeping  the  parts  clean 
through  douching  does  more  toward  terminating  the  disease  than  does 


468  THE  PRACTICE  OF  PEDIATRICS 

the  use  of  any  particular  disinfectant  wash  or  application.  Douching 
of  the  parts  is  to  be  practised  four  times  daily,  if  possible,  with  the  use 
of  two  quarts  of  water.  It  is  useless  to  attempt  the  treatment  of  a 
case  without  provision  for  douching  at  least  twice  a  day.  It  may  be 
remarked  that  this  is  a  very  trying  ti'eatment  for  both  patient  and 
nurse.  Such  is  certainly  the  case,  but  we  are  dealing  with  a  disease  in 
which  only  strenuous  measures  give  hope  of  cure.  In  order  to  receive 
the  douche  most  effectively  the  child  is  placed  on  the  back  on  a  douche- 
pan.  A  glass  female  catheter  attached  to  a  fountain-syringe  is  all  the 
apparatus  required.  The  catheter  is  passed  about  one-half  inch  within 
the  vaginal  orifice,  and  the  water  allowed  to  run.  The  lower  end  of 
the  bag  should  not  hang  higher  than  two  feet  above  the  child's  body. 
Boric  acid  is  a  safe  drug  in  any  household.  For  this  reason  it  is  selected 
instead  of  bichlorid  of  mercury,  permanganate  of  potash,  or  any  other 
antiseptic.  I  am  not  at  all  sure  that  plain  boiled  water  would  not  answer 
just  as  well.  It  would  be  difficult,  however,  to  persuade  many  families 
to  use  the  repeated  douching  without  the  addition  of  some  antiseptic 
to  the  water.  Accordingly,  the  mother  or  nurse  is  instructed  how  to 
prepare  two  quarts  of  a  saturated  solution  of  boric  acid.  This  is  used 
as  a  cleansing  agent.  After  the  parts  are  dried  with  sterile  absorbent 
cotton,  a  dusting-powder  the  formula  of  which  is  as  follows  is  used 
very  freely: 

I^     Acidi  borici .' gr.  xxv 

Pulv.  amyli, 

Pulv.  ziuci  oxidi aagss 

The  powder  is  freely  dusted  into  the  vagina  and  over  the  diseased 
surface  after  the  douche,  and  at  two-hour  intervals,  during  the  time  the 
child  is  awake,  from  early  morning  until  late  at  night.  I  tell  the  atten- 
dants to  'pack  the  parts  with  the  powder.  Over  this  is  placed  absorbent 
cotton  or  gauze,  which  is  covered  with  the  napkin.  The  attendants 
should  be  warned  of  the  danger  of  infecting  themselves  and  other  chil- 
dren in  the  household  with  towels,  sponges,  etc.;  in  fact,  sponges  should 
never  be  used  in  these  cases.  The  danger  of  infecting  the  eyes,  not 
only  of  the  patient,  but  of  the  attendants  and  others  who  may  come  in 
contact  with  the  case,  should  be  carefully  explained.  When  washing  or 
drying  is  necessary,  absorbent  cotton  or  old  linen  should  be  used  and 
immediately  burned.  A  child  suffering  from  gonorrheal  vaginitis 
should  sleep  alone.  Cheese-cloth  napkins  should  be  used  and  burned 
as  soon  as  soiled. 

A  case  treated  as  above  may  recover  in  three  weeks,  though  usually 
from  four  to  eight  weeks  are  required,  and  in  some  cases  the  treatment 
must  be  continued  for  months.  After  we  have  arrived  at  a  point  where 
we  consider  the  case  cured,  there  will  sometimes  be  a  renewal  of  the 
discharge;  the  treatment  must  then  be  resumed. 

Before  the  case  is  finally  discharged,  at  least  two  bacteriologic  ex- 
aminations of  the  vaginal  secretion  should  be  made  in  order  to  deter- 
mine positively  the  absence  of  the  gonococcus. 

What  becomes  of  the  many  cases  in  which  the  treatment  is  not  con- 


ATRESIA  OF  THE  URETHRA  AND  VAGINA         469 

tinued  or  the  cases  that  are  never  treated?  I  am  confident,  from  the 
large  number  of  infant  females  who  have  the  disease  and  its  absence  in 
older  children  after  the  fourth  year,  that  cure  takes  place  spontane- 
ously, without  after-results.  The  gonococci  become  fewer  in  number 
and  eventually  disappear. 

Vaccine  Treatment. — Treatment  of  the  disease  with  the  vaccines 
offers  no  better  results — probably  not  as  good  results  as  are  obtained 
by  local  cleanliness  and  the  above  treatment. 

The  vaccine  treatment  has  been  given  a  thorough  trial  at  the  New 
York  Nursery  and  Child's  Hospital.  This  institution  is  obliged  to 
receive  any  infant  sent  by  the  authorities  with  the  result  that  there 
are  always  a  dozen  or  more  cases  of  vaginitis  in  isolation.  The  use  of 
vaccines  has  been  discontinued  at  this  institution. 

ATRESIA  OF  THE  URETHRA  AND  VAGINA 

Atresia  of  the  Urethra. — This  is  a  congenital  occlusion  or  stricture 
of  the  urethra,  due  to  agglutination  of  the  walls  or  closure  of  the 
meatus  urethrse  by  membrane.     The  obstruction  is  often  incomplete. 

Treatment. — In  some  instances  simple  incision  at  the  meatus  may 
relieve  the  condition.  The  other  cases  will  require  urethrotomy,  com- 
bined, perhaps,  with  forcible  catheterization. 

Atresia  of  the  vagina  may  be  due  to  imperforate  hymen  (atresia  hy- 
menalis)  or  to  the  presence  of  a  transverse  septum  obstructing  the 
passage  at  a  higher  level.  A  rectovaginal  fistula  may  coexist  with 
the  atresia.  Atresia  of  the  vagina  has  been  recognized  as  a  cause  of 
hematocolpos,  hematometra,  and  hematosalpinx.  The  possible  exist- 
ence of  this  malformation  should  be  considered  in  all  cases  of  delayed 
menstruation. 

The  treatment  is  surgical. 


Xm.  NERVOUS  DISORDERS 

HEADACHE 

A  complaint  of  headache,  particulary  repeated  headache,  on  the 
part  of  a  child  should  always  be  respected.  Its  occurrence  is  of  greater 
import  than  in  the  adult. 

In  children  of  any  age  headache  may  be  an  early  symptom  of  men- 
ingitis, particularly  of  the  tuberculous  form,  in  which  the  headache 
may  exist  for  days  without  other  signs  of  illness.  In  eye-strain  head- 
ache is  a  very  prominent  symptom,  and  may  be  the  only  evidence  that 
an  ocular  defect  exists.  In  cases  of  persistent  headache  that  cannot 
otherwise  be  satisfactorily  explained  I  invariably  have  the  eyes  exam- 
ined. Headache  is  often  the  earliest  sign  of  acute  infectious  disease: 
it  is  a  premonitory  symptom  of  scarlet  fever,  measles,  or  pneumonia. 
Persistent  toxemia  from  any  source  may  be  a  cause  of  headache. 
Such  toxemia  may  occur  in  nephritis  and  in  malaria.  The  most  usual 
source,  however,  is  the  intestinal  tract.  With  persistent  toxemia  of 
intestinal  origin,  anemia  is  generally  associated.  This  condition  may 
exist  without  constipation.  Fatigue,  as  a  result  of  overwork  at  school, 
or  hard  play  and  unusual  excitement,  may  be  a  cause  of  headache  in 
neurotic  children.  Late  in  the  school  year  it  is  frequently  encoun- 
tered in  girls.  Examination  of  the  urine  may  show  marked  indi- 
canuria.  Children  are  imitators  of  adults,  and  in  a  family  with  the 
headache  habit  the  child  may  complain  when  the  condition  does  not 
exist.     Such  simulation  may  readily  be  interpreted. 

Treatment. — The  management  of  headache  consists  in  the  discov- 
ery and  removal  of  the  cause.  An  ice-bag  or  an  ice-cloth  applied  to 
the  head  affords  much  relief  in  the  acute  febrile  cases.  Ocular  defects 
should  have  the  benefit  of  rest  and  suitable  glasses  prescribed  by  an 
oculist.  Fatigue  headaches  are  best  controlled  by  limiting  the  amount 
of  work  and  providing  long  periods  of  rest.  Headaches  due  to  intes- 
tinal toxemia  with  the  usual  accompaniment  of  anemia  are  often  most 
difficult  to  relieve.  In  spite  of  our  best  efforts,  the  intestinal  digestion 
may  remain  faulty  for  a  considerable  time.  A  change  of  residence  and 
a  radical  change  in  the  habits  of  life  are  usually  the  best  means  of 
effecting  a  cure.  The  management  of  these  cases  is  considered  in 
detail  under  Persistent  Intestinal  Indigestion  (pp.  205,  206). 

PAYOR  DIURNUS 

Day-terrors  are  of  occasional  occurrence.  My  cases  have  all  been 
due  to  intestinal  toxemia  in  children  who  showed  very  poor  milk  capa- 
city.    The  fright  has  never  been  as  severe  as  that  occurring  at  night. 

470 


NIGHT-TERRORS    (PAVOR   NOCTURNUS)  471 

Illustrative  Cases. — A  boy,  two  and  one-half  years  of  age,  asked  his  nurse  to 
brush  the  bugs  off  his  lap-robe  and  clothes.  When  the  nurse  failed  to  discover  the 
bugs,  the  boy  attempted  to  brush  them  off  himself.  When  asked  what  kind  of  bugs 
they  were,  he  repeated  "all  kinds." 

A  case  almost  identical  with  the  foregoing  was  that  of  another  boy  three  years 
of  age. 

A  girl  four  years  of  age  would  suddenly  stop  her  play  and  hold  conversation 
with  imaginary  people  or  objects  and  maintain  that  the  people  were  present,  and 
describe  their  appearance  and  dress.  As  suddenly  she  would  return  to  play.  At 
these  times  it  was  with  difficulty  that  the  child  could  be  brought  to  her  normal 
condition  of  mind. 

In  all  these  cases  there  was  chronic  intestinal  indigestion,  with 
heavily  coated  tongue  and  foul  breath.  The  children  recovered  en- 
tirely upon  relief  of  the  intestinal  condition. 

Uncontrollable  attacks  of  screaming  in  young  children  have  been 
attributed  to  pavor. 

NIGHT -TERRORS  (PAVOR  NOCTURNUS) 

In  night-terrors  the  child  arouses  from  his  sleep,  thoroughly 
frightened,  imagining  that  animals  or  persons  are  trying  to  injure  him. 
He  begs  to  be  protected.  The  following  morning  he  has  no  recollection 
of  the  occurrence,  and  is  rather  amused  than  annoyed  at  the  episode. 

Etiology. — In  a  great  majority  of  the  cases  the  trouble  is  due  to  a 
deranged  digestion  in  a  neurotic  child.  This,  however,  is  not  neces- 
sarily the  case.  I  have  repeatedly  known  apparently  healthy  children 
to  have  the  attacks.  In  my  most  recent  case  the  terrors  were  due  to  ex- 
cessive fatigue. 

Illustrative  Case. — The  boy,  four  years  old,  had  been  treated  elsewhere  and 
had  received  careful  medication  and  diet.  The  attacks  continued  nearly  every 
night  for  a  year.  The  mother  stated  that  her  own  health  and  the  boy's  were  badly 
affected  because  of  the  broken  night's  rest,  and  she  looked  upon  the  condition  as 
very  serious.  Upon  learning  every  detail  of  the  boy's  life  I  discovered  that 
there  was  an  older  and  very  active  brother  of  six  years  with  whom  the  patient 
played  daily,  and  who  acted  as  a  pacemaker  for  the  patient.  The  older  boy  was 
sent  from  home,  and  a  quiet,  uneventful  life  was  prescribed  for  the  younger  boy. 
There  was  no  change  in  diet,  as  this  was  not  necessary.  For  one  week  8  grains  of 
bromid  of  soda  was  given  at  bedtime  to  break  the  habit.  During  the  next  ten 
days  there  were  two  mild  attacks.  After  this  the  boy  slept  throughout  the  night. 
There  was  no  relapse  for  eighteen  months. 

Such  cases  as  the  foregoing  are  unusual.  Indulgences  in  unusual 
articles  of  diet  cause  many  attacks  which  may  be  compared  to  night- 
mare in  the  adult.  When  repeated  attacks  occur,  it  will  usually  be 
found  that  the  child  is  suffering  from  persistent  intestinal  indigestion, 
or  that  the  evening  meal  is,  as  a  rule,  beyond  the  patient's  digestive 
capacity. 

Illustrative  Case. — A  boy  patient  who  was  four  years  of  age  when  he  came  under 
my  care  had,  during  the  next  five  years,  two  attacks  of  night-terrors  each  year. 
One  attack  occurred  on  the  night  of  his  birthday  and  the  other  on  Christmas  night. 
At  those  times,  in  spite  of  my  repeated  warnings  and  the  repeated  attacks,  he  was 
indulged  in  unsuitable  articles  of  food. 

Overwork  at  school  and  anxiety  regarding  school  duties  and  lessons 
have  been  factors  contributing  to  night-terrors.  Contributing  factors 
also  are  adenoids,  enlarged  tonsils,  and  worms. 


472  THE    PRACTICE    OF   PEDIATRICS 

Treatment. — If  the  patient  is  a  school-child  and  the  case  Is  aggra- 
vated, school  should  be  temporarily  discontinued  and  all  exciting  play 
and  books  of  .an  exciting  nature  forbidden.  The  heaviest  meal  should 
be  taken  at  midday.  The  evening  meal  should  consist  of  cereals,  milk, 
stale  bread  and  butter,  and  stewed  fruits.  The  child  should  never  be 
allowed  to  go  to  bed  unless  an  evacuation  of  the  bowels  has  taken  place 
during  the  previous  twenty-four  hours. 

In  the  very  nervous  and  irritable  cases,  from  5  to  10  grains  of  bromid 
of  soda  may  be  given  at  bedtime.  This  should  not  be  continued  longer 
than  a  week.  If  the  child  is  delicate,  anemic,  or  suffering  from  ade- 
noids, enlarged  tonsils,  or  thread-worms,  these  conditions,  any  one  of 
which  may  contribute  to  night-terrors,  should  receive  proper  treatment. 

GYROSPASM  (SPASMUS  NUTANS) 

Gyrospasm  is  a  functional  nervous  affection  usually  seen  in  children 
under  one  year  of  age.     I  have  seen  but  two  patients  over  one  year  old. 

Etiology. — I  have  seen  a  considerable  number  of  these  patients, 
and  all  have  been  children  suffering  from  malnutrition.  Rachitis  is 
always  present.     Two  of  my  patients  were  mentally  defective. 

Symptoms. — The  disorder  consists  of  a  rhythmic  rotatory  move- 
ment of  the  head,  at  times  from  20  to  40  oscillations  being  made  in  a 
minute.  The  movement  may  not  only  be  lateral,  but  vertical,  which 
constitutes  what  is  known  as  head-nodding.  In  one  of  my  patients 
both  the  lateral  and  vertical  movements  took  place. 

The  oscillations  are  usually,  but  not  invariably,  associated  with 
nystagmus.  The  movements  of  the  head  occur  only  when  the  child  is 
erect,  and  the  oscillations  with  the  nystagmus  are  increased  when  the 
child's  attention  is  focused  on  some  object. 

Prognosis. — The  prognosis  is  good  if  the  child  is  mentally  normal. 
None  of  these  children  die  of  this  disease,  and  practically  no  cases 
are  seen  after  the  eighteenth  month.  With  improvement  in  the  phys- 
ical condition  and  development  of  the  nervous  system,  the  motions 
cease  and  occur  only  under  excitement.  The  disorder  is  essentially 
chronic,  and  the  improvement  is  slow.  The  mother  becomes  dissatis- 
fied with  the  treatment,  and  wanders  from  clinic  to  clinic.  This  ex- 
plains in  part  the  large  number  of  cases  seen  by  pediatrists. 

Treatment. — The  only  treatment  of  value  is  along  nutritional 
lines.  I  have  had  the  opportunity  to  give  a  few  cases  a  fair  trial  with 
sodium  bromid  in  doses  from  12  to  18  grains  daily,  a  treatment  which  is 
generally  advocated  for  this  condition,  but  have  failed  to  note  any  spe- 
cial benefit  from  the  method.  With  an  increase  in  age  and  improvement 
in  nutrition  the  cases  which  I  have  been  able  to  follow  have  slowly 
improved  and  recovered. 

HYSTERIA 

Hysteria  is  a  functional  disorder,  rare  in  young  children,  and  char- 
acterized by  nervous  crises.     My  youngest  patient  was  33-^  years  old 


HYSTERIA  473 

when  first  seen  by  me,  but  the  hysteric  manifestation  had  been  pres- 
ent for  several  months.  Mental,  motor,  or  sensory  manifestations 
may  predominate  in  an  individual  case,  although  in  all  cases  the  condi- 
tion is  associated  more  or  less  directly  with  an  absence  of  mental  control. 
Girls  are  more  frequently  affected  than  boys,  but  some  of  the  most 
typical  cases  coming  under  my  observation  have  been  among  the 
latter. 

Etiology. — We  are  taught  by  neurologists  that  hysteria  is  almost 
invariably  of  hereditary  origin  because  of  its  apparent  direct  trans- 
mission from  parent  to  child.  It  must  be  remembered  that  the 
child,  in  addition  to  being  born  of  an  hysteric  mother,  is  in  constant 
association  with  her.  To  my  mind,  in  hysteria  we  have  exempli- 
fied in  the  most  perfect  degree  the  effect  of  environment.  A  neurotic, 
hysteric  mother  puts  the  whole  family  in  a  state  of  high  nervous 
tension.  I  know  of  several  such  instances.  A  neurotic,  irritable  father 
will  make  the  whole  family  neurotic.  I  know  of  such  instances  also. 
Fortunately  for  the  offspring,  both  conditions  are  seldom  combined  in 
one  family.  When  they  are  (and  I  have  the  children  of  a  few  such 
families  under  my  care),  the  future  of  the  children  is  discouraging. 
When  one  of  the  parents  is  sufficiently  normal  to  offset  a  reasonable 
degree  of  neurosis  on  the  part  of  the  other,  a  stable  equilibrium  may 
be  maintained. 

Imitation  is  one  of  the  strongest  characteristics  of  the  growing  child. 
How  often,  when  arranging  with  the  mother  a  diet-list  for  one  of  these 
nervous,  ill-conditioned  children,  have  I  heard  the  child  say  that  he 
"hated"  cereals,  or  "hated"  vegetables,  or  "hated"  eggs  or  fowl;  or 
that  he  "adored "  some  other  articles  of  food;  this  adoration  and  hatred, 
particularly  the  latter,  often  influencing  the  entire  future  of  the  child; 
for  without  a  properly  regulated  diet  for  every  day  in  the  year  only 
an  inferior  tj'^pe  of  adult  can  be  the  outcome.  In  such  cases  it  will 
usually  be  found  that  the  likes  and  dislikes  of  the  child  are  identical 
with  those  of  the  parents,  whose  preference  has  often  been  expressed 
in  the  presence  of  the  child.  "Heredity"  here  furnishes  to  the  parents 
a  satisfactory  explanation  of  the  child's  limitations  in  diet.  It  will 
usually  be  found  that  parents  who  live  normally  have  children  who  eat 
normally. 

Illnesses  and  ailments  of  different  kinds  should  not  be  discussed 
before  nervous  and  impressionable  children.  Time  and  again  an  in- 
vestigation of  a  peculiar  pain  in  a  child's  head,  side,  or  back  which 
cannot  be  accounted  for  by  the  physical  examination  will  be  explained 
by  a  similar  pain  in  some  older  member  of  the  family. 

Illustrative  Cases. — -In  one  family  I  have  seen  three  generations  of  genuine 
hysteria.  In  the  first  generation  the  father,  chronically  irritable  and  neurotic,  was 
a  business  man  with  large  interests,  rarely  ceasing,  when  at  home,  to  talk  about 
his  ailments  and  their  remedies;  and  the  mother  had  marked  hysteria,  indulging  in 
frequent  attacks,  with  apparent  unconsciousness  lasting  for  hours.  The  daughter, 
brought  up  in  this  atmosphere,  through  heredity  and  environment  soon  became 
markedly  hysteric.  When  some  dispute  arose  in  the  family,  which  was  not  an  in- 
frequent occurrence,  both  she  and  the  mother  would  have  simultaneous  attacks  of 


474  THE    PRACTICE    OF    PEDIATRICS 

hysteria.     In  due  time  the  (laughter  married  and  gave  birth  to  a  daughter,  who 
promises  to  maintain  the  family  traditions,  with  certain  additions  of  her  own. 

A  girl  seven  years  of  age  lived  in  deadly  fear  of  appendicitis  and  developed  an 
attack  of  hysteria  every  time  she  had  a  pain.  She  could  locate  "McBurney's 
point,"  and  knew  the  various  stages  in  the  development  of  the  disease  and  the  steps 
in  the  operation  for  appendicitis.  The  mother's  appendix,  suitably  preserved,  is 
among  the  family  relics,  whence  it  cannot  be  removed.  The  influence  of  heredity 
perhaps  had  the  effect  of  making  the  child  alert,  precocious,  and  impressionable. 
Such  favorable  soil  and  the  constant  association  with  the  hysteric  will  almost 
surely  develop  hysteria  in  a  child. 

Symptoms. — Three  forms  of  hysteria  may  be  seen — the  normal, 
motor,  and  sensory  types.  An  individual  may  show  one,  two,  or  all 
of  the  types. 

Hysteric  patients  will  be  found  who  have  indulged  in  "tantrums" 
from  very  early  life.  They  enjoy  their  seizures,  which  are  usually 
manifested  by  laughing  and  crying  violently  in  alternation;  and  not 
only  do  they  enjoy  the  indulgence  in  an  attack,  but  the  attention  they 
receive.  They  are  usually  obstinate,  and  do  not  attempt  to  exert 
what  mental  control  they  may  possess.  They  may  become  most 
violent.  Upon  attempting  to  quiet  a  strong  girl  of  ten  years  in  a 
violent  seizure  of  hysteric  mania  I  came  out  a  victor,  but  required  the 
use  of  plaster  bandages  as  well  as  the  service  of  a  tailor  before  I  could 
continue  the  work  of  the  day. 

Illustrative  Case. — The  Motor  Type. — A  girl  thirteen  years  of  age  had  not  been 
able  to  walk  for  three  weeks;  she  was  most  calm  and  collected.  Examination 
showed  her  muscle  and  nerve  condition  to  be  normal.  There  was  no  hyperesthesia 
nor  anesthesia,  and  the  muscles  of  the  legs  and  back  were  entirely  under  her  control 
when  she  was  in  bed.  As  soon  as  she  attempted  to  walk  the  legs  gave  way  and 
she  sank  to  the  floor.  About  one  year  before  she  had  passed  through  a  period  when 
the  left  arm  could  not  be  used  for  three  weeks.  She  was  very  fond  of  looking  out 
of  the  window.  She  soon  could  walk  in  the  direction  of  the  window,  but  would 
fail  utterly  when  walking  in  any  other  direction.  Likewise  she  could  stand  by  the 
window  and  in  front  of  the  mirror, — she  was  decidedly  handsome, — but  in  other 
situations  the  legs  would  not  support  the  body. 

The  convulsive  cases  exhibit  every  variety  of  contortion.  The 
patients  throw  themselves  about  in  apparent  unconsciousness,  without 
regard,  yet  it  will  be  remarked  that  they  always  manage  to  fall  in  a  soft 
place.  Hysteric  patients  never  injure  themselves  to  any  extent.  If 
they  pull  their  hair,  they  do  not  pull  very  hard.  They  pull  another 
person's  hair  much  harder  than  their  own. 

Illustrative  Case. — A  girl  of  eleven  upon  little  or  no  provocation  would  pass  into 
a  trance-like  state  and  remain  in  this  condition  for  five  or  six  hours  until  she  became 
very  hungry  or  thirsty.  During  the  attack  it  was  impossible  to  arouse  her  by  any 
ordinary  means.  On  one  occasion  I  cried  "Fire!  Fire!"  in  an  adjoining  room. 
This  promptly  brought  her  to  her  feet.  Later  attempts  along  this  line  were  without 
effect.  I  instructed  that  no  attention  be  paid  to  her  when  in  the  attack.  The 
attacks  then  ceased  to  be  interesting  to  her  and  terminated. 

Globus  hystericus,  hiccup,  and  inability  to  speak,  have  all  been  en- 
countered from  time  to  time. 

Illustrative  Case. — A  girl  of  eight  developed  an  incessant  cough,  which  drove 
the  members  of  the  family  to  distraction,  but  was  easily  controlled  through 
suggestion. 


HYSTERIA  475 

That  imitation  is  a  factor  of  much  importance  is  shown  by  the 
dancing  mania  of  former  days,  and  more  recently  by  the  school  epi- 
demics, necessitating  the  closing  of  the  school. 

Illustrative  Case. — In  a  country  school  a  new  girl  had  habit  chorea.  Two  of  the 
larger  boys  amused  themselves  imitating  her.  Other  small  boys  and  girls  imitated 
the  boys,  and  soon  the  whole  group  of  30  children  were  grimacing  to  such  an  extent 
that  a  temporary  closure  of  the  school  was  necessary. 

Hyperesthesia  and  anesthesia  are  not  common. 

The  Sensory  Type. — This  manifestation  in  children  is  also  quite 
unusual.  Hysteric  anorexia  or  hysteric  vomiting  has  occurred  in  a 
few  instances.  In  hysteric  anorexia  the  patient  may  be  unable  to  eat 
in  the  presence  of  a  certain  person,  or  exhibit  inability  to  eat  in  a  cer- 
tain room  or  locality,  or  be  able  to  eat  only  with  certain  utensils  or  in  a 
favorite  room  or  locality,  or  with  the  body  in  a  special  position. 

Illustrative  Case. — A  girl  three  years  of  age  was  brought  to  me  for  treatment 
because  she  vomited  at  the  table,  over  the  table,  and  over  any  one  who  was  suffi- 
ciently near.  Not  every  meal  was  lost,  and  food  given  between  meals  was  retained. 
There  was  sufficient  disturbance  of  nutrition  to  warrant  anxiety  on  the  part  of  the 
mother.  I  found  the  child  pale,  thin,  undersized,  and  showing  a  moderate  second- 
ary anemia.  From  infancy  there  had  been  some  gastro-intestinal  disturbance, 
and  the  child  had  been  the  source  of  much  anxiety  to  the  mother  in  this  regard. 
For  about  a  year  the  vomiting  at  the  table  had  been  very  distressing.  The  child 
had  been  treated  in  various  ways  for  stomach  disorders  or  disease,  without  any 
improvement  whatsoever.  After  a  thorough  examination  and  review  of  the  case 
I  made  the  diagnosis  of  hysteria,  and  directed  that  the  mother,  who  had  neurotic 
tendencies,  should  keep  apart  from  the  child  as  much  as  possible.  The  child  was 
not  allowed  to  dine  with  the  mother,  but  was  permitted  to  dine  in  the  kitchen  with 
the  maid  of  all  work.  The  vomiting  stopped  at  once.  After  about  ten  days  of 
dining  in  the  kitchen,  during  which  the  patient  showed  marked  physical  im- 
provement, the  maid  was  called  away  on  account  of  illness;  the  child  returned  to 
the  family  table,  and  again  promptly  vomited  once  or  twice  a  day  at  about  the 
completion  of  the  meal.  In  three  days  the  maid  returned  and  the  child  took  up 
dining  in  the  kitchen,  with  the  former  satisfactory  results.  This  continued  for  a 
few  weeks;  then  there  was  a  disagreement  between  mistress  and  maid,  and  the 
maid  left,  never  to  return.  Again  the  child  was  placed  at  the  family  table,  and 
again  the  vomiting  recurred.  Whether  the  child  ate  with  the  family  or  dined 
alone,  the  presence  of  the  mother  was  sufficient  to  produce  the  vomiting.  Ac- 
cordingly, after  many  terrible  trials  and  many  failures,  the  mother,  thoroughly 
distracted,  placed  the  child  in  the  family  of  nearby  relations,  where  there  were 
other  children.     Here  she  retained  her  food  and  throve. 

I  have  treated  other  vomiting  cases  of  similar  nature,  but  none  so 
obstinate. 

Diagnosis.. — The  diagnosis  of  hysteria  is  made  chiefly  by  exclusion 
of  symptoms  referable  to  organic  disease  of  any  nature.  Electric  tests 
and  other  forms  of  examination  will  establish  the  non-pathologic  char- 
acter of  the  illness. 

Duration. — There  is  a  marked  tendency  to  relapse.  Patients  who 
continue  to  live  under  the  original  neuropathic  environment  usually 
continue  to  enjoy  their  hysteria.  Duration  and  prognosis  depend 
upon  the  opportunity  for  right  management  and  cooperation  on  the 
part  of  the  family  and  friends. 

Treatment. — General. — My  results  with  hysteric  children  have 
usually  been  very  good  or  very  poor,  depending  to  a  great  extent  upon 


476  THE    PRACTICE    OF    PEDIATRICS 

my  ability  to  separate  the  child  from  the  family.  By  this  statement 
the  proper  management  of  hysteric  children  is  indicated.  The  child 
should,  if  possible,  be  removed  from  the  unfavorable  family  influence. 
The  boarding-school  has  effectually  cured  several  of  my  cases.  Here 
the  child  is  placed  under  the  care  of  trained  teachers,  who  bring  out  the 
good  and  correct  the  bad  by  reason,  precept,  and  example,  and  thus 
exert  a  continuous  beneficial  influence.  In  the  boarding-school,  plain 
diet,  pleasant  occupation,  agreeable  association,  and  a  scientifically 
regulated  life  replace  the  spoiling  and  coddling,  and  often  the  unsuit- 
able food,  together  with  the  endless  nagging  which  the  neurotic  mother 
is  very  apt  to  indulge  in,  with  the  best  intentions,  of  course,  but  never- 
theless with  a  most  unfortunate  effect  upon  the  child.  If  the  child  is 
too  young  for  a  boarding-school,  or  if  admission  is  denied  him,  he  should 
be  placed  under  the  care  of  some  kindly,  well-balanced  woman  as 
companion  and  instructor,  and  see  as  little  of  his  family  as  possible; 
otherwise  but  little  can  be  expected  from  the  treatment.  Of  course, 
the  conditions  must  be  explained  fully  to  the  parents,  in  order  that  they 
may  make  an  effort  to  regulate  their  bearing  toward  the  child  in  the 
right  direction.  If  the  former  intimate  associations  with  the  child 
continue,  the  good  intentions,  according  to  my  observation,  may  prove 
effective  only  a  very  few  days.  It  is  impossible  to  reform  the  habits 
of  life  of  a  neurotic  adult.  Once  hysteric  always  hysteric  does  not 
come  far  from  the  truth.  If  an  individual  has  grown  that  way,  that 
way  he  will  remain.  The  only  hope  for  the  child  is  in  his  complete 
removal  from  such  unfavorable  influences. 

Physical  and  Mental  Activity. — The  further  treatment  of  hysteric 
children  consists  in  curtailing  the  mental  and  physical  activities,  which 
almost  invariably  have  been  excessive.  A  rational  scheme  of  living 
should  be  formulated.  "Showing  off"  the  child  to  visitors  and  others 
should  be  forbidden.  If  the  patient  is  under  ten  years  of  age,  he  should 
retire  at  7  o'clock  every  night,  and  rise  at  7  every  morning.  It  is  to  be 
understood  by  the  attendant  that  this  does  not  mean  6.45  or  7.15. 
Every  day  after  the  midday  feeding  the  child  should  rest  quietly  in  a 
darkened  room  for  an  hour  or  two.  Whether  he  sleeps  or  not,  he 
should  rest  in  a  recumbent  position  with  clothing  removed.  For  such 
children  exciting  games  of  stress  and  competition  of  every  nature  are 
forbidden.  An  outdoor  life  is  to  be  encouraged.  A  bicycle,  a  pony,  an 
individual  play-room  in  winter,  and  a  tent  on  the  lawn  in  summer, 
should  be  provided  when  possible.  School  instruction  may  be  given, 
but  the  child  is  not  to  be  crowded.  The  amount  of  study  and  school 
work  depends,  of  course,  upon  the  child's  condition.  Until  the  tenth 
year,  however,  there  should  be  but  one  session  (and  that  in  the  morn- 
ing) of  one  and  one-half  to  three  hours.  The  child  should  be  given  a 
tub-bath  or  brine  bath  daily  at  90°F.  (p.  780).  At  the  completion  of 
the  bath  he  should  stand  with  his  feet  in  warm  water  and  be  given  a 
cool  douche  at  70°  to  60°F.,  the  spray  tube  being  attached  to  a  faucet. 
Cold  water  may  be  poured  down  the  spine.  This  application  of  cold 
water  should  be  for  a  few  seconds  only  and  should  be  followed  by 


HABITS  477 

brisk  rubbing  with  a  rough  towel,  which  should  result  in  a  decided  skin 
reaction. 

Treatment  During  Hysteric  Seizure. — During  a  hysteric  seizure  the 
child  should  be  treated  with  kindness,  but  with  firmness.  No  sympa- 
thy should  be  shown.  The  application  of  ice-water  to  the  face  and 
chest  is  usually  sufficient  to  break  up  an  attack.  In  some  cases  a  cer- 
tain amount  of  time  appears  to  be  required  for  a  return  to  the  normal. 

Drugs. — Sedative  drugs,  such  as  the  bromids,  should  not  be  used. 
Cases  have  come  under  my  observation  showing  the  bromid  rash. 
Such  treatment,  as  also  the  use  of  the  opium  derivatives,  cannot  be  too 
strongly  condemned.  Drugs  that  increase  the  appetite  and  improve 
nutrition  should  be  given.  I  have  found  that  iron  and  arsenic  answer 
well  in  these  cases,  as  most  of  the  patients  show  a  secondary  anemia. 
For  a  child  from  five  to  ten  years  of  age  the  following  prescription  has 
been  useful: 

I^     Liquoris  potassii  arsenitis gtt.  xc 

Extract!  ferri  pomati gr.  x 

Quininse  bisulphatis gr.  Ix 

M.  div.  et  ft.  capsulse  no.  xxx. 

Sig. — Take  one  after  each  meal. 

If  constipation  results  from  the  use  of  the  small  doses  of  iron,  }/^  to 
l^  grain  of  the  extract  of  cascara  may  be  added  to  each  capsule.  If  the 
child  cannot  swallow  a  capsule,  the  following  may  be  used : 

I^     Liquoris  potassi  arsenitis gtt.  Ixxii 

Ferri  et  ammonise  citratis gr.  xxiv 

Elix.  simplicis 5ss 

Aquae q.  s.  ad  5iv 

M.  Sig. — One  teaspoonful  after  each  meal  in  a  glass  of  water. 

The  iron  and  arsenic  may  advantageously  be  alternated  with  pure 
cod-liver  oil, — one  to  two  drams  after  meals, — each  medicine  in  turn 
being  given  for  seven  successive  days.  Alcohol  should  form  no  part 
of  the  medication  of  these  children.  In  using  the  so-called  liquid  pro- 
prietary foods,  it  is  to  be  remembered  that  some  contain  a  consider- 
able percentage  of  alcohol. 

HABITS 

Children  readily  acquire  habits,  good  or  bad.  Under  the  manage- 
ment of  an  intelligent  attendant,  directed  by  the  physician,  natural 
tendencies  toward  the  repetition  of  an  act  may  be  turned  to  the  child's 
inestimable  advantage.  In  earliest  infancy  the  habit  of  taking  the 
nourishment  at  definite  periods  should  be  established,  and  as  the  child 
increases  in  age,  proper  habits  of  sleep  and  rest  must  also  be  acquired. 
The  child  should  be  bathed  at  a  stated  time  and  aired  at  a  stated  time 
each  day,  and,  in  general,  in  order  to  fulfil  the  requirements  of  vigorous 
animal  life,  his  life  should  conform  to  a  routine  in  which  there  is  but 
little  variation.  As  our  sole  object  is  the  production  of  a  normal  adult, 
only  those  habits  tending  toward  proper  growth  and  development 
should  be  encouraged.     The  habit  of  self-entertainment  is  important. 


478  THE    PRACTICE    OF    PEDIATRICS 

An  infant  who  requires  to  be  constantly  in  arms  when  awake  will  have 
a  tired  attendant,  and  usually  will  develop  into  a  tired  and  irritable 
child. 

Bad  Habits  and  Their  Correction. — Among  the  bad  habits  early 
acquired  and  difficult  to  break  are  those  of  thumh-sucking  or  finger-sucking 
and  the  use  of  the  "pacifier."  The  penalty  paid  by  these  children  for 
such  indulgence  is  thickened,  boggy  lips,  due  to  hypertrophy  of  the 
orbicularis  oris  muscle  and  adjacent  structures.  Persistent  sucking 
also  produces  a  forward  projection  of  the  upper  incisor  teeth  and  an 
angular  deformity  of  the  upper  jaw.  The  correction  of  the  rubber- 
nipple  and  pacifier  habit  is  readily  accomplished  by  the  immediate 
withdrawal  of  these  articles.  The  child  will  experience  several  fretful 
days  and  make  association  temporarily  unpleasant  for  those  about  him. 
The  thumb-sucking  habit  may  be  corrected  by  having  the  child  wear 
a  mitten  or  glove  made  of  muslin  or  old  linen  which  is  shirred  and  tied 
at  the  wrists.  The  Hand-I-Hold  Mit  (Fig.  61)  answers  the  purpose  of 
preventing  thumb-  and  finger-sucking  better  than  any  other  article. 
The  child  has  full  use  of  his  arms,  yet  the  hands  contained  in  the  alumi- 
num mit  are  free  from  manipulation.  Applying  bitter  drugs  to  the 
fingers  or  thumb  may  be  effective  in  controlling  the  habit.  The  tinc- 
ture of  aloes  or  a  solution  of  bisulphate  of  quinin,  one  dram  to  two 
ounces  of  water,  is  generally  used.  The  fingers  should  be  repeatedly 
moistened  with  the  solution.  Mothers  will  sometimes  tell  us  with  con- 
siderable amusement  that  the  application  of  the  bitter  drug  to  the 
finger  makes  no  difference  to  the  child;  he  appears  to  like  the  taste  of 
quinin  or  aloes.  The  child,  however,  soon  tires  of  the  bitter  taste,  and 
continued  use  of  the  remedy  will  always  stop  the  habit.  Biting  the 
finger-nails  may  likewise  be  remedied  by  the  use  of  these  bitter 
solutions. 

Picking  or  ruhhing  the  finger-tips  with  the  fingers  of  the  opposite 
hand  is  rather  an  unusual  habit.  It  may  cause  considerable  hyper- 
trophy of  the  ends  of  the  fingers,  so  that  they  will  acquire  an  appear- 
ance not  unlike  that  occasioned  in  cardiac  disease.  Mechanical 
restraint  is  our  best  preventive.  The  constant  use  of  gloves  or  the 
apphcation  of  strips  of  adhesive  plaster  will  break  the  habit. 

Head-banging  is,  fortunately,  an  unusual  habit.  It  consists  in 
repeatedly  elevating  and  bringing  the  head  forcibly  down  on  the  mat- 
tress when  asleep.  This  I  have  seen  done  in  one  instance  with  sufficient 
force  to  produce  vibrations  in  the  other  rooms  of  the  house  and  inter- 
fere with  the  repose  of  the  occupants.  Every  means  and  device  for 
preventing  the  banging  was  tried  without  effect.  Finally  the  patient 
became  such  a  nuisance  to  his  family  that  he  was  made  to  sleep  in  a 
hammock.  This,  to  the  best  of  my  knowledge,  was  the  means  of  cur- 
ing the  condition. 

It  is  surprising  in  how  many  ways  children  develop  habits  of 
manipulating  different  parts  of  the  body. 

Head-rolling. — Head-rolling  is  practised  with  the  child  resting  on 
its  back;  the  head  is  rolled  rapidly  from  side  to  side.     A  two-year  old 


MASTURBATION  479 

child  at  the  Nursery  and  Child's  Hospital  immediately  began  this  rolling 
whenever  it  was  rested  on  its  back.  As  many  as  50  oscillations  would 
be  made  in  a  minute.  In  this  position  the  child  continued  until  over- 
come by  fatigue  or  sleep.  We  were  unable  to  control  this  habit  and 
the  child  passed  out  of  the  hospital  with  the  rolling  in  full  force. 

Illustrative  Cases. — One  of  my  most  troublesome  cases  was  that  of  a  child  one 
syear  old  who  came  to  me  with  an  ear  stretched  to  twice  its  normal  size.  During 
'  the  greater  part  of  the  waking  hours  the  child  grasped  and  pulled  at  the  top  of  the 
left  ear. 

Another  patient  was  brought  because  of  the  habit  of  burrowing  the  right  thumb 
into  the  right  nostril.  The  nostril  had  become  stretched  to  at  least  three  times  its 
normal  size,  causing  a  most  peculiar  deformity. 

An  eight-year-old  girl  developed  the  habit  of  striking  her  left  leg  at  the  calf 
with  the  heel  of  her  right  shoe  when  walking.  Her  stockings  soon  became  worn 
and  soiled,  and  the  child  presented  a  ridiculous  appearance  in  public.  In  running 
or  in  going  up  and  down  stairs  the  habit  was  not  practised.  The  girl  was  brought 
to  me  because  of  the  peculiar  habit,  which  had  been  kept  up  for  several  months. 
She  had  received  the  usual  punishments  and  rewards  without  effect.  Upon 
discovering  that  she  only  practised  the  leg-banging  when  walking,  I  advised  a 
treatment  which  proved  effective.  This  consisted  in  not  allowing  the  child  to 
walk  for  six  months.  She  was  made  to  run  or  walk  rapidly,  whenever  walking 
was  necessary. 

A  girl  six  years  old,  without  eczema  or  any  evidence  of  irritation,  cam.e  to  me 
because  of  the  habit  of  rubbing  the  right  thigh.  While  walking  a  city  block  she 
would  raise  the  clothing  with  the  right  hand  and  rub  the  outer  lower  third  of  the 
thigh  for  a  second.  This  act,  according  to  the  mother,  would  be  repeated  a  hun- 
dred times  a  day  if  there  was  no  interference.  The  treatment  suggested  in  this 
case  was  simple  and  effective.  Several  thicknesses  of  a  roller  bandage  were  used 
in  covering  up  the  favorite  skin  area.  Whatever  gratification  was  experienced  by 
the  manipulation  was  thus  done  away  with,  and  the  habit  was  promptly  broken. 
The  parts  were  kept  bandaged  for  three  months. 

The  most  pernicious  habit,  that  of  masturbation,  is  referred  to 
below. 

It  is  impossible  to  make  more  than  general  suggestions  for  the 
correction  of  bad  habits  in  children.  When  there  is  manipulation  of 
the  mouthy  the  sense  of  taste  can  usually  be  made  to  aid  us.  In  other 
instances  restrictions  of  a  mechanical  nature  may  be  necessary.  In  the 
ear-pulling  case,  a  tight-fitting  muslin  cap  was  worn  constantly  and  the 
right  hand  kept  pinned  to  the  clothing.  Punishment,  rewards,  and 
ridicule  all  may  be  employed  in  the  treatment  of  these  cases.  As  a 
rule,  however,  such  measures  are  not  as  effective  as  mechanical 
restraint.  Bad  habits  as  to  hours  for  feeding  and  sleeping,  as  well  as 
the  habit  of  carrying  a  child  in  arms — all  may  be  corrected  by  doing  the 
right  thing  at  the  right  time  and  having  a  sufficient  amount  of  courage 
to  persist.  It  is  to  be  remembered  that,  regardless  of  age,  a  child  is 
never  harmed  by  rigid  discipline  properly  applied. 

MASTURBATION 

Before  the  fifth  year  a  great  many  more  cases  of  masturbation 
are  seen  among  girls  than  among  boys.  After  that  age  it  is  more 
frequent  in  boys.  The  most  common  means  of  practising  masturba- 
tion in  either  sex  in  infancy  is  by  leg-rubbing.  Contact  by  means  of 
the  edge  of  a  chair  or  the  corner  of  a  sofa  or  any  object  against  which 
pressure  may  be  exerted  is  not  infrequently  the  means  used  by  older 


480  THE  PRACTICE  OF  PEDIATRICS 

girls.  Manipulation  of  the  parts,  while  only  occasionally  seen  in  girls, 
is  the  usual  method  of  boys  after  the  third  year.  My  youngest 
patient  was  a  female  child  six  months  of  age  who  was  a  "leg-rubber," 
and  who  evidently  passed  through  a  complete  orgasm.  In  many  the 
habit  will  be  indulged  in  several  times  a  day. 

In  boys  the  primary  causes  of  the  practice  are  an  elongated  foreskin, 
adherent  prepuce,  and  phimosis.  The  handling  of  the  parts  necessary 
to  keep  the  uncircumcised  clean  is  an  exciting  factor.  In  girls,  vulvitis 
and  vaginitis,  and  adhesions  of  the  clitoris  with  the  retained  smegma 
and  resulting  irritation,  are  frequent  causes.  It  is  a  popular  notion 
that  thread-worms  may  be  an  exciting  factor,  but  among  many  cases 
of  masturbation  and  many  cases  of  thread-worms  I  have  never  seen 
both  conditions  in  the  same  child. 

Prophylaxis. — Masturbation  is  much  easier  to  prevent  than  cure. 
In  boys,  prevention  lies  in  keeping  a  clean,  free  glans,  which  in  the 
great  majority  of  male  infants  can  be  obtained  only  after  proper  sur- 
gical procedures.  The  elongated,  thickened,  uncut  portion  of  the 
foreskin  usually  seen  below  the  glans  after  a  ritual  circumcision  is  but 
little  better  than  a  free,  elongated  prepuce.  Slitting  of  the  foreskin 
on  the  dorsum  gives  a  condition  very  similar  in  character  to  that  of  a 


Fig.  59. — Knee-crutch.* 

long,  redundant  foreskin.  In  girls,  prevention  to  a  certain  degree  Con- 
sists in  keeping  the  parts  clean  through  washing  them  once  a  day  with 
great  gentleness,  and  the  free  use  of  non-irritating  absorbent  powders. 
A  powder  composed  of  equal  parts  of  powdered  starch  and  oxid  of  zinc 
gives  very  satisfactory  results. 

Treatment. — When  the  habit  of  masturbation  has  been  once  estab- 
lished, the  first  step  is  to  eliminate  the  cause,  if  it  can  be  discovered, 
and  put  the  parts  in  a  normal  condition.  Circumcision  in  boys,  and 
releasing  the  adhesions  of  the  clitoris  in  girls,  with  the  maintenance 
of  cleanliness  and  as  little  manipulation  as  possible,  are  absolutely 
essential. 

The  urine  should  be  examined,  and  if  found  highly  acid,  should  be 
corrected  by  diet  and  by  the  use  of  bicarbonate  of  soda,  six  to  twelve 
*  Made  for  the  author  by  George  Ermold  Co.,  201  East  23d  St.,  New  York  City. 


MASTURBATION 


481 


grains  being  given  daily,  according  to  the  age  of  the  patient.  If  red 
meat  has  formed  a  considerable  part  of  the  diet,  the  quantity  should  be 
reduced  and  given  not  oftener  than  three  times  a  week. 

Having  removed  all  possible  sources  of  local  irritation,  we  are  in  a 
position  to  use  restrictive  measures,  as  it  is  through  such  treatment 
only  that  a  cure  will  finally  be  effected.  If  the  practice  is  prevented 
the  habit  will  soon  be  forgotten.  The  older  the  child,  the  more  difficult 
will  be  the  cure.  The  restrictive  measures  employed  depend  to  a 
considerable  extent  upon  the  age,  sex,  and  method  of  practice.     In 


Fig.  60. — Brace  used  to  prevent  manual  masturbation.* 

the  case  of  young  children  of  both  sexes  who  practise  leg-rubbing,  a 
large  napkin  of  some  coarse  material,  or  a  towel,  should  be  placed  over 
the  napkin  usually  worn,  and  applied  in  the  same  way,  so  as  to  keep  the 
legs  widely  separated.  After  the  napkin  age  a  large  towel  may  be 
used,  if  necessary,  for  the  same  purpose,  or  the  knee-crutch  (Fig.  59) 
may  be  employed.  Some  children  will  indulge  only  when  in  a  certain 
chair  or  in  a  certain  position. 

IllustraUve  Cases. — A  very  troublesome  case  in  a  girl  seventeen  months  old  was 
treated  without  success  for  several  weeks,  when  I  discovered  that  the  child  prac- 
tised the  act  only  when  in  her  high  chair,  as  by  leaning  forward  and  grasping  the 
projecting  arms  she  managed  to  bring  the  necessary  pressure  to  bear  upon  the 
genitals.     The  use  of  the  chair  was  discontinued,  and  there  was  no  further  trouble. 

Another  girl  six  years  of  age  was  an  inveterate  masturbator.     She  had  been 

*  Made  for  the  author  by  George  Ermold  Co.,  201  East  23d  St.,  New  York  City. 
31 


482 


THE    PRACTICE    OF    PEDIATRICS 


treated  by  several  physicians.  The  act  was  repeated  daily,  sometimes  two  or 
three  times  a  day,  usually  by  contact,  such  as  by  pressure  against  the  corner  of  a 
table,  sofa,  or  chair.  When  in  bed,  she  indulged  in  the  practice  by  manipulation. 
She  had  become  pale,  thin,  and  hysterical,  and  as  she  was  a  member  of  a  prominent 
familj'-,  great  concern  was  felt  for  her.  The  external  genitals  were  congested  and 
swollen  as  a  result  of  the  direct  irritation,  otherwise  they  were  normal.  It  seemed 
that  here  was  a  case  where  eternal  vigilance  was  the  price  of  safety.  The  gravity 
of  the  condition  was  apparent,  and  the  parents  readily  agreed  to  my  suggestion 
that  the  child  should  never  be  left  alone.  The  mother  and  the  nursery  maid  took 
turns  in  being  with  the  child  in  the  daytime.  A  trusty  middle-aged  woman  was 
selected  for  the  night  watch.  I  directed  that  no  reference  be  made  to  the  habit, 
but  that  the  child  should  be  severely  punished  if  the  practice  was  attenipted, 

This,  however,  was  not  needed.  This  child,  as 
IS  the  case  with  all  older  children,  masturbated 
in  secret,  and  as  she  was  never  left  alone, 
stopped  the  practice.  She  was  given  suitable 
food,  teaching  by  a  visiting  governess  was  be- 
gun, and  hard  play  was  soon  advised,  as  her 
physical  improvement  was  rapid.  As  there  was 
no  further  tendency  to  masturbate,  the  night 
watch  was  withheld  after  six  months.  The 
child  was  kept  under  the  closest  observation, 
however,  for  a  much  longer  time.  Cooperation 
to  such  a  degree  as  in  this  family  may,  how- 
ever, rarely  be  secured. 

Older  children  who  practise  manipu- 
lation of  the  parts  can  usually  be  watched 
during  the  daytime,  but  the  habit  is  fre- 
quently indulged  in  on  going  to  bed,  af- 
ter the  lights  are  out,  and  in  the  early 
morning,  particularly  when  prevented 
during  the  day.  In  such  instances  I 
have  been  obliged  to  advise  mechanical 
restraint.  An  inexpensive  and  effective 
means  is  a  piece  of  tape,  which  is  tied  in 
the  center  around  the  child's  neck  in  a 
flat  knot,  leaving  the  two  ends  long 
enough  to  be  securely  tied  around  the 
wrists,  so  as  to  allow  a  free  movement 
of  the  hands  above  the  umbilicus.  The 
child  can  use  the  handkerchief,  and  ad- 
just the  bed-clothing,  but  cannot  touch 
the  genitals.  If  the  patient  is  a  girl  and  a  masturbator  by  contact 
with  any  object,  or  a  leg-rubber,  a  large  bath-towel,  if  worn  like  an  in- 
fant's napkin,  will  aid  materially  in  discouraging  the  practice.  A 
brace  (Fig.  60),  constructed  of  steel,  with  a  hinge-joint  to  allow  the 
arm  to  be  extended  to  an  angle  of  about  45  degrees,  has  been  used 
with  success  in  a  few  cases.     This  brace  is  worn  only  at  night.* 

The  "Hand-I-Hold  Mitt."t — As  a  means  for  the  prevention  of 
scratching,  thumb-  and  fi^nger-sucking,  nose-boring,  ear-and  lip-puUing, 
and  masturbation  the  "Hand-I-Hold  Mit"  renders  good  service.  The 
child  has  free  use  of  the  arms  and  the  fingers  are  movable  inside  the 

*  This  device  had  its  origin  with  Dr.  Gerald  Webb  of  Colorado  Springs. 

t  Manufactured  by  R.  M.  Clark  and  Co.,  246  Summer  Street,  Boston,  Mass. 


Fig.  61.— The  Hand-I-Hold 
Babe  Mit  and  method  of  ap- 
plying :  a,  First,  roll  sleeve  over 
ball  to  expose  opening,  then  in- 
sert the  child's  hand;  b,  second, 
tie  tape  at  wrist  and  pin  with 
safety-pin  to  dress  at  elbow.  If 
mit  is  not  held  in  place  firmly 
enough,  use  a  broad  piece  of 
cheese-cloth  in  place  of  tape. 
Bind  this  firmly  around  the 
wrist  and  tie;  c,  a;-ray  view 
showing  freedom  of  hand. 


INFANTILE    CONVULSIONS  483 

mit.     In  eczema,  however,  it  may  serve  as  a  very  attractive  means 
of  rubbing  the  diseased  surfaces. 

HICCUP 

Hiccup  is  a  spasm  of  the  diaphragm,  usually  due  to  gastric  irrita- 
tion from  the  distention  of  the  stomach  or  intestine  with  gas,  or  over- 
loading of  the  stomach  with  food.  Under  such  conditions  the  spasm 
is  usually  of  little  consequence,  and  may  readily  be  relieved,  if  the 
attack  is  prolonged,  by  an  enema  of  soap-water  and  a  laxative  dose  of 
rhubarb  and  soda.  With  any  grave  illness,  however,  it  is  a  symptom 
of  serious  import.  Hysteric  girls  often  have  hiccup  to  quite  an  alarm- 
ing degree.  The  attack  usually  follows  a  period  of  unusual  excitement. 
In  these  cases  from  20  to  30  grains  of  bromid  of  soda  repeated  in  from 
twenty  to  thirty  minutes  will  usually  control  the  spasm. 

INFANTILE  CONVULSIONS 

A  convulsion  consists  of  a  temporary  loss  of  consciousness,  associ- 
ated with  rhythmic  clonic  contractions  of  various  muscles  of  the  body. 
We  are  dealing  with  a  symptom,  and  not  with  a  disease. 

During  the  early  days  of  life  a  convulsion  is  always  of  serious  im- 
port, as  it  frequently  is  the  result  of  a  birth  trauma  and  suggests  a 
serious  brain  lesion  which  may  terminate  in  early  death  or  result  in 
spastic  paralysis,  or  idiocy,  or  both. 

Etiology. — Infants  and  young  children  are  peculiarly  susceptible 
to  convulsions  because  of  lack  of  inhibitory  control,  due  to  insufficient 
development  of  the  motor  centers  in  the  cortex,  which,  in  conse- 
quence, discharge  the  more  readily.  A  convulsion  may  be  looked 
upon,  as  a  motor  discharge  affecting  either  the  entire  muscle  structure 
or  only  a  portion  thereof.  Convulsions,  therefore,  indicate  cortical 
irritation.  The  irritation  may  be  due  to  injury  of  the  brain  structure, 
as  previously  mentioned,  birth  trauma  being  the  usual  cause  of  convul- 
sions in  the  very  young,  or  the  convulsion  may  be  the  result  of  irritation 
from  meningitis,  tumors,  hydrocephalus,  or  trauma  in  later  life,  such  as 
a  fall  or  blow  on  the  head. 

Illustrative  Case. — An  infant  of  eleven  months  fell  from  his  baby  carriage  to  the 
stone  pavement.  Convulsions,  repeated  and  severe,  continued  until  the  bleeding 
area  in  the  cortex  was  located,  the  skull  was  opened,  and  the  bleeding  vessel  was 
tied. 

Convulsions  may  be  due  to  remote  causes. 

Rachitis. — Rachitis,  according  to  my  observation,  is  a  most  fertile 
contributing  cause.  The  reason  for  this  is  not  clearly  understood. 
Various  theories  have  been  advanced.  Probably  the  nerve-centers 
share  with  other  portions  of  the  body  in  malnutrition  and  lack  of  de- 
velopment. In  a  rachitic  the  inhibitory  control  is  of  a  very  low  order. 
In  many  rachitic  children  it  is  surprising  how  little  irritation  may  bring 
on  a  seizure. 

Gastro-intestinal  Causes. — An  immense  majority — over  90  per  cent. 
— of  the  cases  of  convulsions  coming  under  my  notice  have  been  due  to 


484  THE    PRACTICE    OF    PEDIATRICS 

gastro-intestinal  disorder,  most  frequently  in  the  form  of  acute  indi- 
gestion due  to  unsuitable  articles  of  diet.  Rachitic  children  supplied 
many  of  these  cases. 

If  the  irritation  is  sufficiently  severe,  convulsions  may  occur  in  the 
most  robust.  Thus,  a  boy  of  three  years  had  repeated  convulsions  un- 
til he  was  relieved  of  43  large  round-worms  (lumbricoids). 

Convulsions  of  intestinal  origin  may  be  due  either  to  the  effects  of 
toxins  supplied  by  abnormal  digestive  processes,  or  to  direct  intestinal 
irritation.  A  case  of  the  latter  type  was  seen  in  the  New  York  Infant 
Asylum,  where  a  child  had  repeated  convulsions  and  died  in  a  seizure. 
At  the  autopsy  a  fourth  of  a  small  orange  was  found  in  the  intestine. 

Thymus  Gland. — Enlargement  of  this  gland  has  been  present  in  six 
cases  of  fatal  convulsions.  The  majority  of  the  cases  have  been  seen 
in  hospital  work,  where  the  enlargement  of  the  thymus  could  be  proved 
at  autopsy. 

I  have  seen  in  private  work  two  fatal  cases  presenting  the  same 
symptoms. 

Convulsions  of  toxic  origin  may  usher  in  pneumonia,  scarlet  fever, 
or  any  of  the  acute  infectious  diseases. 

Particularly  disturbing  cases  are  the  newly-born,  who  develop  not 
convulsions  but  grimaces  and  slight  twitchings  of  the  face,  with  a 
tendency  to  stupor  and  irregular  respirations,  all  very  bad  signs  indeed 
in  a  newly-born  baby.  These  cases  may  go  on  to  the  development 
of  true  convulsions,  but  many  never  show  more  active  symptoms  than 
those  mentioned.  Particularly  unfavorable  is  it  if  these  various 
manifestations  are  combined  even  to  a  mild  degree.  Sooner  or  later 
the  child  appears  for  treatment  because  of  retarded  mental  develop- 
ment. 

Dr.  W.  Sharpe  of  New  York  has  performed  the  decompression 
operation  on  several  of  these  infants ;  those  with  active  nervous  symp- 
toms, and  those  in  which  there  was  nothing  but  defective  mentality 
with  a  suggestive  early  traumatic  history.  I  have  been  surprised  at 
the  amount  of  lesions,  hemorrhage,  cysts,  etc.,  which  are  to  be  found, 
with  comparatively  little  attending  reflex  manifestations. 

Uremic  convulsions  are  to  be  classed  under  this  heading. 

Convulsions  are  frequently  the  termination  of  a  prolonged  broncho- 
pneumonia or  enterocolitis.  I  have  seen  a  large  number  of  these  cases 
in  institution  work. 

Heredity  apparently  plays  but  little  part  as  regards  predisposition. 

Dentition. — Dentition  may  indirectly  be  a  cause  in  producing  in- 
digestion, with  resulting  irritation  and  toxemia.  I  have  had  three 
patients  who  had  convulsions  with  every  tooth  cut  and  without  demon- 
strable associated  digestive  disorder. 

Phimosis. — Two  boys  had  repeated  convulsions  which  subsided 
when  they  were  circumcised  and  relieved  of  much  smegma  and  local 
irritation. 

Asphyxia. — A  strong  boy  nine  months  of  age  was  taken  in  bathing 
by  his  mother.     A  large  wave  enveloped  and  separated  them.     The 


INFANTILE    CONVULSIONS  485 

baby  was  unconscious  when  found.  With  returning  consciousness  he 
passed  into  a  convulsive  state  which  lasted  several  hours.  Evidently 
there  was  a  cerebral  hemorrhage,  as  the  child  is  now  an  imbecile  and 
had  been  perfectly  normal  before. 

Tetany  (p.  491). — Severe  convulsions,  although  exceptional, 
may  be  present  in  severe  tetany.  In  tetany  the  manifestations  are 
usually  those  of  continuous  tonic  contractions. 

Repetition. — With  each  convulsion  the  inhibitory  control  is  lessened, 
and  each  succeeding  seizure  requires  less  cortical  irritation  than  its 
predecessor.  Gowers  states  that  30  per  cent,  of  the  cases  of  epilepsy 
have  their  origin  in  so-called  simple  infantile  convulsions. 

Manifestations. — Convulsions  vary  greatly  in  their  manifestations. 
The  seizure  may  be  so  slight  as  to  be  scarcely  recognized.  These  are 
the  so-called  "inward"  convulsions.  There  may  be  a  momentary 
spasm  of  the  body,  with  shght  twitching  of  the  face  and  extremities, 
after  which  the  child  appears  normal  or  sleepy  and  dull  for  a  few  mo- 
ments. The  convulsion,  on  the  other  hand,  may  be  most  intense  and 
prolonged.  The  onset  is  sudden.  There  are  usually  twitchings  of  the 
muscles  of  the  face  and  incoordinate  movements  of  the  extremities. 
There  are  alternate  contractions  and  relaxations  of  all  the  muscles. 
The  eyes  become  set,  and  the  child  is  unconscious.  There  is  frothing 
at  the  mouth,  and  the  breathing  is  stertorous  and  labored.  The  child 
may  rapidly  pass  out  of  the  convulsive  state  or  become  quiet,  with  in- 
frequent twitchings,  and  thus  remain  for  hours.  In  a  fatal  case  the 
temperature  was  111°F. — as  high  as  my  thermometer  would  register. 
The  temperature  was  reduced,  and  the  child  lived  eight  hours,  but 
never  regained  consciousness. 

In  many  instances  the  child  passes  from  one  convulsion  into 
another.  During  active  treatment,  such  as  the  hot  bath  and  chloro- 
form administration,  the  seizure  will  apparently  cease,  and  the  child 
will  show  signs  of  returning  consciousness.  As  soon  as  the  treatment  is 
discontinued  the  convulsion  is  again  repeated. 

Prognosis. — I  have  seen  a  considerable  number  of  cases  of  fatal 
convulsions,  and  do  not  look  upon  any  attack  with  unconcern.  The 
prognosis  depends  entirely  upon  the  general  condition  of  the  patient 
and  the  direct  cause  of  the  convulsion.  In  the  convulsions  of  scarlet 
fever,  pneumonia,  and  gastro-enteric  disease  there  is  usually  but  little 
danger  of  life.  If  the  attack  is  due  to  an  enlarged  thymus,  the  prognosis 
is  unfavorable. 

A  convulsion  may  be  serious  in  its  immediate,  as  well  as  in  its  re- 
mote, effects.  One  convulsion  may  produce  cerebral  hemorrhage, 
which  may  change  the  entire  future  of  the  patient,  producing  spastic 
paralysis  or  idiocy  or  both.  About  10  per  cent,  of  the  cases  of  epilepsy 
originate  in  indigestion — the  so-called  ''dentition  convulsions."  In 
these  rachitis  plays  an  important  etiologic  part. 

Under  my  observation  several  children  under  one  year  of  age,  in 
apparently  good  health,  have  died  as  the  result  of  convulsions.  In  one 
case  we  found,  upon  autopsy,  as  above  noted,  one-fourth  of  an  orange 


486  THE    PRACTICE    OF    PEDIATRICS 

in  the  small  intestine.  In  six  the  convulsions  were  due  to  enlarged 
thymus  glands.  In  three  of  these  cases  there  had  been  no  previous 
symptoms  indicating  the  existence  of  this  condition.  The  patients 
were  strong,  robust  infants.  Two  were  breast-fed.  The  diagnosis 
was  confirmed  by  autopsy  in  four  cases,  which  included  the  breast-fed. 

Treatment. — Immediate  Treatm,ent. — When  a  convulsion  occurs, 
the  patient  should  at  once  be  undressed  and  placed  in  a  mustard  bath 
(p.  780),  at  a  temperature  of  105°F.  While  in  the  bath,  he  should  re- 
ceive brisk  friction  of  the  trunk,  and  particularly  of  the  extremities. 
At  the  same  time  an  attendant  may  give  an  injection  of  soap- water.  In 
a  great  majority  of  the  cases,  in  less  than  five  minutes  the  child  will  show 
evidence  of  a  return  to  consciousness.  As  soon  as  he  can  swallow,  two 
teaspoonfuls  of  castor  oil  should  be  given. 

After  a  seizure  the  patient  should  be  kept  very  quiet  for  twenty- 
four  to  forty-eight  hours.  An  ice-bag  or  cold  cloths  should  be  applied 
to  the  head,  and  a  guarded  hot-water  bottle  kept  at  the  feet. 

Diet. — The  diet  should  be  the  lightest.  Chicken  broth,  weak  beef- 
tea,  and  thin  gruels  should  constitute  the  nourishment  for  a  day  or  two. 
A  second  seizure  is  more  easily  produced  than  the  first,  and  a  third 
easier  than  the  second. 

The  Use  of  Chloroform  and  Sedatives. — In  case  the  attack  is  a  very 
severe  one,  when  the  child  is  slow  to  respond  or  when  he  passes  rapidly 
from  one  convulsion  to  another,  chloroform  inhalations,  regardless  of 
the  age,  should  be  given  in  sufficient  quantity  to  prevent  the  seizures 
until  the  intestinal  canal  can  be  emptied,  and  sufficient  sodium  bromid 
and  chloral  can  be  given  by  mouth  or  rectum  to  prevent  a  recurrence. 

Rectal  Medication. — To  a  child  under  one  year  of  age  8  grains  of 
sodium  bromid  and  3  grains  of  chloral  may  be  given  by  rectum  in  2 
ounces  of  mucilage  of  acacia.  After  the  first  year,  from  3  to  5  grains 
of  chloral  may  be  given  with  10  to  20  grains  of  sodium  bromid.  It  is 
best  to  attach  to  the  syringe  a  soft-rubber  catheter,  No.  18  American, 
or  a  small  rectal  tube.  The  catheter  should  be  introduced  for  at  least 
9  inches,  so  that  the  solution  may  be  carried  to  the  descending  colon, 
where  it  will  be  retained  better  than  if  introduced  with  the  small  hard- 
rubber  tip  just  within  the  anus.  The  bromid  and  chloral  may  be 
repeated  at  intervals  of  two  to  six  hours,  as  required  to  control  the 
convulsions,  and  continued  in  diminished  doses  as  long  as  there  are  no- 
ticeable signs  of  nervous  irritability,  such  as  twitching  and  involuntary 
muscular  contractions. 

Sedatives  Internally  Administered. — If  the  child  can  swallow,  5 
grains  of  sodium  bromid  in  3^^  ounce  of  water  may  be  given,  and  repeated 
at  intervals  of  one  to  four  hours,  until  the  convulsions  are  controlled. 

Hypodermic  Medication. — Morphin  hypodermically  is  rarely  re- 
quired. It  should  be  used  only  when  other  means  fail.  A  child  one 
year  of  age  may  be  given  ^■so  grain,  and  this  may  be  repeated  in  two 
hours,  though  usually  it  will  not  be  required.  Under  one  year,  3^o  to 
3=^0  grain  may  be  given;  under  six  months,  morphin  should  be  omitted. 


LARYNGISMUS    STRIDULUS  487 

LARYNGISMUS  STRIDULUS 

In  laryngismus  there  is  a  spasm  of  the  larynx  involving  the  muscles 
of  both  inspiration  and  expiration.  This  rarely  occurs  after  the  eight- 
teenth  month.     I  have  seen  it  but  a  few  times  in  older  children. 

Etiology. — The  part  played  by  the  thymus  in  laryngismus  stridulus 
may  be  a  very  important  role.  1  have  seen  two  typical  cases  of  laryn- 
gismus end  fatally,  with  enlarged  thymus  as  the  cause  of  death.  I 
require  an  rc-ray  examination  of  every  case  of  laryngismus. 

Morbid  Anatomy. — No  definite  lesion  has  been  found  to  account 
for  the  spasm,  which  occurs  in  association  with  a  wide  variety  of  morbid 
states,  as  well  as  without  any  apparent  pathologic  condition. 

Symptomatology. — The  attacks  are  usually  excited  by  some  dis- 
turbance of  the  child's  mental  state.  Thus,  crying  ushers  in  most  of 
the  paroxysms.  The  child  attempts  to  draw  in  the  breath  preparatory 
to  the  cry,  and  the  laryngeal  spasm  begins.  There  may  be  several 
short,  whistling  inspirations,  each  attempt  being  less  successful  than 
the  first.  The  whole  procedure  requires  but  a  few  seconds.  The  face 
is  first  red,  then  blue  and  cyanosed.  The  absence  of  respiration  con- 
tinues for  an  indefinite  time — usually  but  a  few  seconds.  Then  the 
spasm  subsides,  and  the  child  "catches"  his  breath,  which  is  signaled 
by  a  short  inspiratory  crow,  followed  by  a  series  of  longer  and  more  suc- 
cessful inspirations.  The  child  cries,  the  blood  becomes  oxygenated, 
the  normal  color  returns,  and  all  is  well  until  the  next  attack. 

A  patient  three  months  of  age  had  from  twenty  to  thirty  seizures  a  day,  and  the 
attacks  ceased  only  with  an  improvement  in  the  child's  general  condition. 

Laryngismus  is  very  frequent  in  rachitic  and  poorly  nourished 
children.  The  seizures  are  induced  by  fright  or  anger  and  the  attacks 
cease  in  many  instances,  with  spoiling  the  child,  allowing  him  to  have 
his  own  way,  by  improving  his  nutrition  and  in  the  use  of  tr.  belladonna 
and  bromides.  If  the  thymus  was  the  all-important  factor  in  all  cases, 
we  would  not  expect  a  response  to  the  treatment  outlined.  Further, 
autopsies  on  infants  who  have  had  laryngismus  do  not  always  show 
involvement  of  the  thymus.  We  must  continue  to  look  for  the  expla- 
nation of  many  of  our  cases  as  belonging  to  the  family  of  spasmophilics. 

The  attacks  may  be  milder  or  more  severe  than  the  foregoing.  In 
the  mild  cases  complete  apnea  does  not  take  place.  In  others  the  laryn- 
geal spasm  is  complete  from  the  onset.  The  child  attempts  to  cry, 
and  falls  into  what  the  mother  calls  "a  faint,"  becoming  thoroughly 
relaxed  and  unconscious.  Such  attacks  as  these  always  cause  me  much 
anxiety,  as  they  suggest  strongly  the  possibility  of  enlarged  thymus 
and  sudden  death.  The  period  of  unconsciousness  may  persist  for  a 
variable  time,  ranging  from  a  few  seconds  to  a  minute  or  two. 

Congenital  Larijngeal  Stridor. — The  obstruction  is  of  a  mild  degree, 
present  a  greater  part  of  the  time.  It  is  relieved  by  excitement  and  at 
its  worst  when  the  child  is  asleep. 

Diagnosis. — The  diagnosis  is  made  by  the  sudden  onset  of  difficult 
breathing,  the  rapid  return  to  normal  breathing,  and  the  continuation 


488  THE    PRACTICE    OP    PEDIATRICS 

of  normal,  unimpeded  breathing  between  the  attacks.  In  susceptible 
subjects  the  larjmgismus  may  occur  with  whooping-cough  and  with 
acute  catarrhal  larjmgitis.  These  diseases  have  a  distinct  symptoma- 
tology of  their  own,  and  need  cause  no  confusion. 

Prognosis. — The  prognosis  in  the  main  is  good,  but  when  one  has 
seen  sudden  death  in  infants  in  private  families  and  others  in  hospital 
work,  all  with  spasmodic  larjmgeal  association,  he  does  not  have  the 
confidence  in  the  outcome  of  a  convulsion  that  is  claimed  by  many 
writers. 

Duration. — Prompt  results  under  treatment,  except  in  mild  cases, 
are  the  exception.  The  attacks  may  continue,  varying  widely  in  num- 
ber, for  several  weeks.  The  intervals  between  attacks  lengthen  and 
the  attacks  are  less  severe. 

Treatment. — Drugs. — The  management  is  divided  into  two  parts: 
the  immediate  relief  of  the  spasm,  and  the  treatment  of  the  patient's 
debilitated  physical  condition,  if  such  condition  exists.  From  my 
observation,  the  most  satisfactory  method  of  relieving  spasm  in  the 
mild  cases — those  in  which  the  unconsciousness  is  of  but  a  few  seconds' 
duration — is  by  inverting  the  patient  and  at  the  same  time  slapping 
him  on  the  back.  Splashing  cold  water  in  the  child's  face  may  be  of 
advantage  in  some  cases,  but  I  have  found  it  of  but  little  service.  In 
cases  which  are  sufficiently  prolonged  to  resist  inversion  and  slapping 
on  the  back,  a  quick  resort  to  alternate  hot  and  cold  tub-baths,  at  60°F. 
and  120°F.  respectively,  has  been  useful.  If  recovery  is  not  prompt, 
intubation  or  tracheotomy  should  be  performed,  followed  by  attempts 
at  artificial  respiration.  Between  the  attacks  the  patient  should  re- 
ceive small  doses  of  antipyrin  and  sodium  bromid.  Under  six  months 
of  age  3^^  grain  of  antipyrin  and  2  grains  of  sodium  bromid  may  be  ad- 
ministered in  1  dram  of  cinnamon-water,  6  doses  being  given  in  twenty- 
four  hours.  From  the  age  of  twelve  months  to  the  third  year,  1  to  2 
grains  of  antipyrin  with  2  to  4  grains  of  sodium  bromid  may  be  admin- 
istered in  1  dram  of  cinnamon-water,  6  doses  being  given  in  twenty-four 
hours.  The  only  disadvantage  in  the  use  of  these  drugs  lies  in  the  fact 
that  these  children  may  have  faulty  digestion,  which  condition  may  be 
aggravated  by  the  sodium  bromid.  When  this  effect  is  observed,  the 
bromid  should  be  omitted  and  the  antipyrin  given  alone.  Antipyrin 
apparently  never  produces  any  unfavorable  effects  upon  gastric 
digestion. 

Rectal  Medication. — Colon  medication  may  be  of  considerable  serv- 
ice in  these  cases,  and,  when  indicated,  bromid  and  chloral  are  our 
most  reliable  sedatives.  To  a  child  of  six  months  or  under,  1  grain  of 
chloral  with  5  grains  of  sodium  bromid  may  be  given  in  2  ounces  of 
mucilage  of  acacia  by  the  bowel;  to  a  child  of  six  to  twelve  months, 
2  grains  of  chloral  and  8  grains  of  sodium  bromid  in  3  ounces  of  muci- 
lage of  acacia;  to  a  child  of  twelve  to  twenty-four  months,  2  grains  of 
chloral  and  10  grains  of  sodium  bromid  may  be  given  in  2  ounces  of 
mucilage  of  acacia.  The  bromid  and  chloral  should  not  be  adminis- 
tered oftener  than  once  in  six  hours. 


SPASMOPHILIA  489 

The  method  of  administration  is  as  follows:  A  large  soft-rubber 
catheter  or  a  small  rectal  tube,  attached  to  a  Davidson  syringe,  should 
be  introduced  at  least  9  inches  into  the  rectum,  so  as  to  reach  the  de- 
scending colon.  The  child  should  rest  on  the  left  side,  with  the  but- 
tocks elevated  on  a  pillow  so  that  they  are  higher  than  the  shoulders. 
After  the  withdrawal  of  the  tube  the  position  of  the  child  should  be 
maintained  for  several  minutes  in  order  to  aid  in  the  retention  of  the 
fluid. 

All  sources  of  reflex  irritation  should  be  removed.  If  difficult  den- 
tition is  a  factor,  the  troublesome  tooth  should  be  brought  through  the 
gum.  Adenoids,  thread-worms,  adherent  prepuce,  and  constipation  all 
should  receive  proper  attention.  Particularly  must  these  children  be 
kept  free  from  all  sources  of  mental  excitement,  such  as  loud  talking, 
the  overattention  of  adults,  and  the  rough,  active  play  of  older  children. 

Diet. — The  dietetic  management  of  debilitated,  rachitic  children 
suffering  from  laryngismus  is  the  same  as  that  of  other  debilitated 
children.  (See  Malnutrition,  p.  92.)  In  general,  they  should  be  given 
as  high  a  proteid  diet  as  is  compatible  with  their  digestive  powers. 
Thus,  if  there  is  intolerance  of  cow's  milk  given  in  suitable  dilution, 
there  should  be  no  hesitation  in  advising  the  employment  of  a  wet- 
nurse.  If  the  proprietary  foods  are  given  they  should  be  used  with 
cow's  milk.  For  children  over  one  year  of  age  cow's  milk,  cereals  con- 
taining a  large  amount  of  nitrogen,  such  as  oatmeal  and  soy-bean 
gruel,  soft-boiled  eggs,  beef-juice,  and  scraped  beef  should  form  a  large 
part  of  the  diet. 

SPASMOPHILIA 

The  term  spasmophilia  was  originated  by  Finkelstein  and  is  applied 
to  a  state  of  abnormal  nervous  irritability  in  infants,  the  expression  of 
which  is  in  one  or  more  forms  of  spasm,  principally  holding  the  breath, 
convulsions,  carpopedal  spasm  and  laryngospasm.  By  some  authors 
''spasmophilia"  is  used  to  designate  only  the  latent  form  of  this  disease 
to  which  is  applied  the  name  tetany. 

Spasmophilia  in  all  its  forms  is  most  common  in  bottle-fed  infants 
after  the  third  month.  Heredity  exerts  some  influence  in  the  causation 
and  several  cases  are  not  uncommon  among  children  of  the  same 
parents.  Spasmophilia  and  rickets  are  very  closely  associated  and 
spasmophilia  like  rickets  has  been  ascribed  to  a  deficiency  of  lime  salts 
in  the  system.  Quest  has  demonstrated  the  existence  of  such  a  defi- 
ciency in  the  brains  of  children  dying  from  tetany.  Harriot  and 
Rowland  have  shown  a  marked  reduction  of  calcium  in  the  blood  of 
infants  with  marked  cases,  and  McCallum  and  Voegtlin  have  shown 
the  same  condition  in  the  blood  of  animals  with  experimental  tetany 
induced  by  extirpation  of  the  parathyroids,  thus  confirming  Escherich's 
view  that  the  disease  might  be  due  to  hemorrhages  or  other  lesions  in 
these  glands. 

Toxemia  from  infectious  diseases  or  digestive  disorders  conduces  to 


490  THE    PRACTICE    OF    PEDIATRICS 

outbreaks  of  spasmophilia,  and  most  of  the  active  manifestations 
are  observed  in  the  late  winter  and  early  spring. 

The  pathological  findings,  apart  from  the  presence  occasionally  of 
hemorrhages  in  the  parathyroids,  are  the  lesions  of  associated  rickets. 

Symptoms. — Lowenbm-g  conveniently  divides  spasmophilia  into 
two  types:  latent  spasmophilia  and  manifest  spasmophilia.  Latent 
spasmophilia  is  recognized  by  the  presence  of  abnormal  electrical  re- 
actions together  with  reflex  phenomena  of  nervous  origin  which  may  be 
ehcited  by  mechanical  stimulation.  The  amount  of  electrical  current 
required  to  produce  a  kathodal  opening  contraction  in  the  muscles  of  a 
spasmophilic  infant  is  always  less  than  the  amount  necessary  to  pro- 
duce the  same  reaction  in  a  normal  infant.  Such  response  to  a  current 
of  less  than  5  milliamperes  indicates  positive  spasmophilia.  Chvostek's 
sign  is  an  evanescent  facial  contraction  elicited  in  spasmophilics  after 
the  second  month  of  age,  upon  tapping  the  cheek  just  below  the 
zygomatic  process  of  the  superior  maxilla.  Trousseau's  sign  is  the 
occurrence  of  a  characteristic  carpal  contraction  in  an  extremity 
following  ligation  of  the  wrist  or  ankle  in  such  manner  as  completely 
to  occlude  the  blood  supply.  The  peroneus  phenomenon  obtained  by 
tapping  the  peronei  muscles  consists  in  a  drawing  up  of  the  foot  with 
the  toes  raised  and  slightly  elevated.  Theimich's  lip  sign  consists  in  a 
protrusion  or  pouting  of  the  lips,  elicited  by  tapping  the  orbicularis 
oris.  So-called  manifest  spasmophilia  is  characterized  in  addition  by 
laryngospasm,  carpopedal  spasm,  eclampsia  or  convulsions  of  a  general 
character  and  by  a  peculiar  induration  (hard  edema)  of  the  hands 
and  feet.  The  laryngospasm  occurs  upon  slight  disturbance  of  the 
child's  nervous  balance  and  may  even  occur  during  sleep.  It  is  com- 
mon during  fits  of  crying  and  differs  from  congenital  stridor  particu- 
larly in  the  peculiar  crow  which  in  spasmophilic  laryngospasm  follows 
a  state  of  apnea  and  cyanosis  of  possibly  a  full  minute's  duration. 
Many  attacks  in  one  day  are  not  uncommon. 

The  carpopedal  spasm  consists  in  tonic  contractions  of  the  hands 
and  feet.  The  larger  joints  are  held  flexed,  the  thumb  adducted  and 
the  foot  typically  in  a  position  of  equinovarus. 

Eclampsia  in  spasmophilics  is  marked  by  the  occurrence  of  clonic 
convulsions  independent  of  brain  lesions,  nephritis  and  epilepsy. 

The  hard  edema  of  the  hands  and  feet  is  supposedly  a  vasomotor 
phenomenon. 

Diagnosis. — Among  the  conditions  frequently  confounded  with 
spasmophiHa  are  epilepsy,  tetanus,  pertussis,  enlarged  thymus,  con- 
genital stridor,  laryngeal  stridor  and  retropharyngeal  abscess.  Of 
these,  epilepsy  is  most  difficult  to  exclude.  The  typical  reflexes  and 
electrical  reactions  of  spasmophilia  are  of  the  greatest  value  for  differen- 
tiation in  doubtful  cases. 

Prognosis. — Under  intelhgent  care  and  feeding  the  outlook  is  good. 
Progress  may  be  confirmed  by  the  observance  of  a  steadily  closer  and 
closer  approximation  to  the  normal  in  reflexes  and  electrical  response. 

Treatment. — Maternal  nursing  and  wet  nursing  are  of  greatest 


TETANY  491 

value  not  only  in  preventing  tetany  but  in  limiting  its  progress.  Holt 
affirms  that  to  infants  under  eight  months  of  age  who  give  symptoms  of 
tetany  woman's  milk  should  be  suppKed  if  possible.  Aside  from  this 
the  fundamental  management  of  spasmophiHa  is  essentially  that  of 
rickets.  Most  cases  do  well  on  cod  Hver  oil  provided  the  oil  can  be 
borne  by  the  digestion  and  is  best  given  about  half  an  hour  after  the 
feeding.  Calcium  bromid  in  simple  solution  is  generally  recommended 
as  the  sedative  of  choice.  The  dose  of  the  salt  should  be  sufficient 
to  control  the  spasm  and  may  vary  from  20  to  40  grains  daily.  Where 
this  is  unobtainable  or  ineffective,  chloral,  chloroform  or  even  morphine 
hypodermatically,  in  dosage  up  to  Koo  grain,  may  be  given.  Gastric 
and  intestinal  lavage  are  of  value  when  there  has  been  overloading  of 
the  digestive  tract  or  toxic  absorption  therefrom,  and  when  there  are 
general  convulsions  or  pronounced  spasms  of  the  extremities,  warm 
baths  are  to  be  employed. 

CONGENITAL  STRIDOR 

Attention  was  first  called  to  this  disease  by  Rilliet  and  Barthez  in 
1853.  The  condition  is  characterized  by  an  inspiratory  crow,  slight  in 
character  but  fairly  constant  when  the  child  is  quiet  and  asleep.  It 
usually  disappears  under  stress  such  as  crying.  The  sound  produced 
has  been  variously  described  as  a  crow,  a  cluck,  a  croak,  etc. 

It  appears  at  birth,  or  within  a  few  days  and  continues  for  months. 
In  a  very  pronounced  case  under  my  observation,  the  stridor  contin- 
ued until  the  child  was  18  months  of  age.  So  noisy  was  the  breathing 
during  sleep  that  it  could  be  heard  in  an  adjoining  room  with  the  doors 
closed.  As  a  rule  the  stridor  gradually  lessens  and  ceases  before  the 
child  is  1  year  of  age. 

Etiology. — Various  explanations  have  been  offered  as  to  the  cause  of 
the  stridor.  It  is  probably  due  to  a  bilateral  abductor  insufficiency, 
a  general  relaxation  of  the  larynx  with  the  result  that  during  inspiration 
there  is  a  partial  collapse  of  the  muscular  equipment  and  the  lumen  of 
the  larynx  is  narrowed  in  consequence.  As  the  child  grows  older  the 
parts  enlarge,  the  tissues  become  firmer  and  a  better  nerve  control  is 
established  and  the  inspiratory  obstruction  is  gradually  relieved. 

Differential  Diagnosis. — So  characteristic  is  congenital  stridor  that 
one  can  hardly  become  confused  with  anything  else.  Beginning  at 
birth  and  continuing  with  but  little  intermission  in  pronounced  cases, 
it  is  most  pronounced  when  the  child  is  quiet  and  when  asleep.  It 
disappears  under  stress.  There  is  no  hoarseness;  no  air-hunger.  The 
obstruction  involves  inspiration  only  and  is  not  sufficient  to  produce 
discomfort. 

Treatment. — No  treatment  is  required. 

TETANY 

Tetany  is  a  condition  characterized  by  persistent  tonic  contractions 
of  the  muscles,  usually  of  the  upper  and  lower  extremities.  In  rare 
instances  cases  will  be  seen  in  which  the  peculiar  tonic  contraction  in- 
volves aU  the  muscles  of  the  body. 


492  THE    PRACTICE    OF    PEDIATRICS 

Age. — Tetany  is  rarely  seen  after  the  second  year,  though  cases  are 
occasionally  reported  as  occurring  in  older  children. 

Tetany  is  most  commonly  seen  in  marasmic  infants  suffering  from 
intestinal  derangements  of  a  not  very  active  type.  Occasionally  it 
occurs  in  well-nourished  children. 

Etiology. — In  the  great  majority  of  instances  tetany  occurs  in  in- 
fants suffering  from  malnutrition  and  under  one  year  of  age.  Rachitis 
has  been  present  in  the  majority  of  my  cases.  In  all  cases  seen  by  me 
malnutrition  or  pronounced  digestive  disturbance  has  been  present. 

Illustrative  Case. — A  baby  three  months  of  age  was  given  a  high  fat  mixture 
(7  per  cent.)  in  order  to  supplement  the  mother's  milk.  After  a  few  feedings  the 
child  developed  convulsions,  with  the  typical  tonic  contractions.  Under  treatment 
the  mental  condition  cleared,  but  general  muscle  contractions  continued,  which 
evidently  caused  great  pain.  The  child  was  absolutely  rigid,  with  both  the  lower 
and  the  upper  extremities  in  the  characteristic  position,  which  continued  for  several 
days. 

The  actual  cause  of  this  disease  is  still  obscure,  but  from  time 
to  time  new  light  is  being  thrown  upon  the  subject.  The  majority  of 
the  cases  are  seen  during  the  winter  and  early  spring  months,  and, 
owing  to  this  fact,  Kassowitz's  theory  of  a  respiratory  infection  has 
received  strong  confirmation.  Escherich,  Ganghofner,  and  others 
have  found  that  manifest  tetany  and  laryngospasm  in  children  increase 
during  the  beginning  of  winter,  and  gradually  reach  their  highest  point 
in  February  and  March,  after  which  they  diminish  in  frequency  until 
midsummer,  when  the  incidence  is  practically  zero.  Escherich's 
statistical  table  of  240  cases  shows : 

Month I       II  III   IV    V     VI    VII    VIII    IX    X     XI  XII 

Number  of  cases 29     51    59    45    10      7        0  14       2       21     16 

In  a  recent,  rather  extensive  work,  Wilcox,  of  New  York,  found 
that  during  the  months  of  December,  January,  and  February,  he  ob- 
tained the  greatest  number  of  middle-grade  reactions,  while  three  of 
his  cases  of  frank  tetany  occurred  in  February  and  two  each  in  Decem- 
ber and  January.  The  incidence  of  hyperirritability  was  greatest  in 
December. 

It  appears,  from  the  literature  on  the  subject,  that  the  frequency 
of  tetany  varies  considerably  in  different  countries  and  cities;  in  some 
localities  the  cases  are  almost  frequent  enough  at  least  to  suggest  an 
epidemic.  In  infancy  males  seem  to  be  more  frequently  affected  than 
females. 

According  to  Fischl,  fully  63  per  cent,  are  rachitic;  this,  of  course, 
will  vary  in  different  countries.  Kassowitz  has  demonstrated  the 
similar  relation  to  the  time  of  year  existing  between  the  incidence  of 
tetany  and  that  of  the  rachitic  affections.  He  came  to  the  conclusion 
that  there  must  be  an  intimate  relation  between  the  two.  Wilcox 
concludes  that  the  child's  irritability  varies  directly  with  the  general 
condition  of  nutrition,  and  that  the  well-developed  and  nourished 
respond  much  less  readily  to  galvanism  than  those  underfed  and  below 
the  normal  weight. 


TETANY  493 

Seligmiiller,  Pott,  Thiemich,  and  others  are  convinced  that  spas- 
mophiUa  (tetany,  laryngospasm,  and  eclampsia  infantum)  possesses  in 
a  well-marked  degree  the  characteristics  of  heredity.  Thiemich's  deci- 
sion has  come  from  a  dozen  observations  at  the  Breslau  Kinderklinik 
relating  to  families  in  which  the  mother  had  laryngospasm  or  eclampsia 
in  her  childhood,  and  still  shows  a  pronounced  facial  phenomenon  as 
a  residuary  latent  symptom. 

Cold,  intestinal  parasites,  bowel  infections,  chronic  intestinal  dis- 
turbances (of  which  there  were  fully  73  per  cent,  in  Fischl's  cases),  and 
an  enlarged  thymus,  have  all,  in  turn,  been  regarded  as  causative  fac- 
tors. Concerning  the  latter  theory,  which  was  advanced  by  Paltauf, 
one  must  consider  the  contrast  existing  between  the  pasty  "  lymphatic  " 
type  and  the  lean  and  imperfectly  developed  child,  in  which  the  evi- 
dences of  the  spasmophilic  diathesis  are  almost  solely  found. 

It  seems  improbable  that  the  disturbance  has  anything  to  do  with 
the  sugar,  fat,  or  protein,  since  no  harm  results  by  adding  any  of  these 
substances  to  a  diet  consisting  of  carbohydrates,  which  tend  to  diminish 
irritability.  On  the  other  hand,  whey  acts  precisely  as  does  cow's 
milk  in  increasing  both  mechanical  and  electric  irritability,  and  it 
might  be  supposed  that  it  contains  in  solution  a  substance  which  is 
concerned  in  the  production  of  the  symptoms. 

Considerable  evidence  has  been  accumulated  of  late  concerning 
calcium  metabolism  and  its  relation  to  tetany.  So  far  the  conclusions 
arrived  at  by  different  observers  vary,  but,  nevertheless,  there  are  a 
few  points  on  which  a  unanimous  opinion  exists.  Experiments  in 
physiology  have  shown  that  the  peripheral  nerve  irritability  can  be  in- 
fluenced by  salt  solutions,  and  only  lately  have  the  researches  of  Holb 
shown  that  it  is  not  one  salt  alone,  but  the  interaction  with  other  salts, 
which  influences  nerve  irritability;  either  a  diminution  of  the  sodium 
or  an  increase  of  the  calcium  diminishes  irritability.  This  fact  has 
suggested  that  the  etiology  existed  in  salt  metabolism. 

Due  to  these  observations,  Czerny  commenced  some  experiments 
on  the  chemical  examination  of  brains,  which  were  carried  out  by 
West,  who  showed  that  there  was  a  diminution  of  the  calcium  content 
of  the  brains  of  children  with  tetany;  he  further  pointed  out  that,  by 
feeding  calcium-poor  food  to  dogs,  the  irritability  of  the  peripheral 
nerves  was  diminished,  while  Sabbatini  demonstrated  that  the  applica- 
tion of  calcium  to  the  cortex  diminished  the  electric  excitability. 
Stoeltzner,  attempting  to  repeat  these  observations,  obtained  some- 
what contradictory  results.  Rosenstern,  along  with  other  observers, 
approached  the  subject  from  the  clinical  aspect  and  fed  calcium  salts 
in  cases  of  the  spasmophilic  diathesis,  producing  a  remarkable  diminu- 
tion in  the  nerve  irritability,  the  effect  of  which  disappeared  in  twenty- 
four  hours,  the  same  results  being  obtainable,  only  more  rapidly,  by 
the  intravenous  injection  of  the  calcium  salts. 

An  examination  of  the  blood  in  this  condition  has  shown  a  consider- 
able diminution  of  the  salt,  while,  on  the  other  hand,  there  is  known  to 
exist  an  increased  output  of  calcium  in  the  urine  and  feces.     Similar 


494 


THE    PRACTICE    OF    PEDIATRICS 


results  have  been  obtained  in  this  country  by  McCallum  and  Voegtlin 
in  experiments  on  parathyroidectomized  dogs.  Further  explanation 
is  offered  in  postoperative  tetany  in  adults.  When  the  parathyroids 
have  been  wholly  or  partially  removed,  the  symptoms  ensuing  are 
relieved  by  the  administration  of  calcium  by  mouth,  the  effect  passing 
off  in  a  few  hours.  In  infantile  tetany  little  result  has  been  obtained 
by  the  administration  of  calcium  by  mouth. 

Pathology. — No  constant  lesions  have  been  located  that  may  be 
associated  with  tetany.  Thus  far  no  uniform  anatomic  changes  in  the 
parathyroids  have  been  reported.  The  most  usual  findings  are  hemor- 
rhage, recent  or  old;  cysts,  and  staining.  Fischl,  in  a  somewhat  recent 
article,  published  the  postmortem  findings  in  his  fatal  cases.  He 
found  tuberculous  meningitis,  bronchopneumonia,  hemorrhagic  infil- 
tration of  the  brain,  edema,  and  chronic  intestinal  inflammation.     In 

one  case  seen  by  me  there 
was  a  pachymeningitis. 
Autopsies  on  other  infants 
in  whom  tetany  was  present 
failed  to  reveal  any  dis- 
eased condition  of  the 
nervous  system. 

Symptoms. — The  ap- 
pearance of  a  child  with 
tetany  is  characteristic. 
The  symptoms  vary  only 
in  their  intensity. 

In  mild  cases  there  may 
be  simply  an  adduction  of 
the  thumb  on  the  palm  of 
the  hand,  giving  rise  to 
the  term  the  "accoucheur 
hand."  With  this  phe- 
nomenon there  will  usually  be  an  extension  of  the  feet,  caused  by 
marked  contraction  of  the  tendo  Achillis. 

In  the  more  pronounced  cases  the  hands  are  flexed  on  the  arms, 
and  the  fingers  are  lightly  contracted  over  the  adducted  thumb  (Fig. 
62).  The  feet  are  held  in  a  marked  extended  position,  with  the  toes 
flexed  toward  the  plantar  surface  of  the  foot.  With  the  second  and 
third  row  of  phalanges  extended,  a  similar  phenomenon  is  also  some- 
times seen  in  the  fingers.  Usually  the  joints  at  the  elbow,  shoulder, 
hip,  and  knee  may  be  moved  without  discomfort.  Attempts  at  forcing 
the  other  joints  to  the  normal  position  are  met  with  resistance  and 
evidence  of  pain.  The  knee-jerk  is  markedly  exaggerated.  There  is 
an  increased  response  to  both  the  galvanic  and  faradic  current.  Mus- 
cle irritation  may  or  may  not  cause  various  phenomena.  Trismus  has 
never  been  present  in  my  cases. 

Muscle  Irritability. — Evidence  of  muscle  and  mechanical  irritability 
may  be  demonstrated  in  the  following  ways:  ^ 


Fig.  62. — Hand  in  tetany. 


TETANY  495 

The  Chvostek  sign  depends  on  the  heightened  irritabihty  of  the  facial 
plexus  (some  believe  it  to  be  reflex),  which,  on  being  tapped  with  the 
finger  or  a  percussion-hammer  midway  between  the  zygoma  and  the 
angle  of  the  mouth,  produces  a  contraction  at  the  ala  of  the  nostril, 
the  angle  of  the  mouth,  and,  in  marked  cases,  the  inner  canthus  of  the 
eye  and  eyebrow.  This  symptom  is  given  various  grades  of  impor- 
tance by  authors.  Thiemich's  conclusions  are  that  "the  facial  should 
be  stricken  from  the  list  of  nervous  stigmas,  and  must  be  regarded  even 
in  late  childhood  as  a  pathognomonic  sign  of  latent  tetany,  even  if  this 
disease  remains  continuously  a  symptomless  anomaly  of  the  nervous 
system."  This  sign  was  found  in  but  one  of  Wilcox's  cases,  and  it  will 
be  found  in  perhaps  half  of  all  cases. 

Schultz's  sign  is  produced  by  stroking  the  skin  over  the  zygoma, 
which  in  extreme  cases  of  tetany  produces  a  contraction  similar  to  the 
Chvostek.     In  comparatively  few  cases  can  this  sign  be  demonstrated. 

Trousseau's  Sign. — Shutting  off  the  blood-supply  in  the  elbow  or 
groin,  through  pressure,  is  followed,  after  a  varying  interval,  by  the 
typical  carpal  or  pedal  spasm. 

Duration. — -The  condition,  under  my  observation,  has  lasted  from 
a  day  or  two  to  two  to  six  weeks.  A  return  to  the  normal  is  usually 
slow.  Cases  that  are  entirely  relieved  in  less  than  a  week  are  extremely 
rare.  When  the  disease  disappears  rapidly,  we  are  not  sure  that  it 
may  riot  return,  possibly  in  a  more  severe  form. 

Diagnosis. — The  diagnosis  is  not  at  all  difficult,  and  is  made  by  the 
characteristic  contraction  of  the  hands  and  feet,  which  occurs  in  no 
other  condition.  While  perhaps  the  nervous  phenomena  might  sug- 
gest cerebral  disease,  the  absence  of  mental  symptoms  excludes  it. 

Electric  Irritability. — -In  tetany  the  electric  reactions  may  be  said 
to  be  of  distinct  diagnostic  value.  It  seems  very  difficult  to  establish 
exactly  normal  reactions  for  children,  as  many  will  react  low  one  day 
and  high  another,  and  then  again  the  reactions  vary  with  changes  in 
the  digestive  and  metabolic  processes.  It  must  be  kept  in  mind  that 
the  electric  reactions  are  not  always  diagnostic  of  tetany,  but,  on  the 
other  hand,  there  is  now  no  doubt  that,  by  this  method  of  diagnosis, 
cases  hitherto  not  suspected  of  tetany  may  be  brought  to  correct  diag- 
nosis. Just  what  exact  electric  findings  are  essential  to  a  diagnosis 
is  still  a  matter  of  dispute.  Escherich  believed  that  in  normal  children 
only,  KCC  appears  under  5,  and  that  only  occasionally  may  anodal 
closure  be  present  with  this  current  strength. 

Wilcox  cites  the  grades  of  electric  irritability: 

1.  Normal,  in  which  KCC  occurs  under  5.  Sometimes  ACC  is 
found  at  5  or  just  below  it. 

2.  The  middle  grade,  or  anodal  hyperirritability,  in  which  KCC  is 
less  than  5,  and  AOC  is  less  than  ACC  and  less  than  5. 

3.  Tetany,  in  which  all  four  reactions  are  less  than  5.  A  suggestive 
tetany  is  the  occurrence  of  AOC  less  than  ACC  and  the  appearance  of 
KCC  tetanus. 

The  incidence  of  tetany  varies,  due  presumably  to  the  varying  at- 


496  THE    PRACTICE    OF    PEDIATRICS 

titudes  of  the  observers  as  to  what  constitutes  a  true  diagnosis.  Num- 
erous authors  give  figures  varying  from  6  per  cent,  down  to  0.7  per 
cent,  in  artificially  fed  children  under  three  years  of  age. 

Technic. — The  simplest  and  most  efficient  instrument  is  one  sup- 
plied by  Wappler  and  Co.,  of  New  York.  It  consists  of  dry  cells  which 
supply  a  galvanic  current  and  contain  a  switch  for  reversing  the  polar- 
ity, a  rheostat  for  controlling  the  current  and  a  balanced  milliampere- 
meter  measuring  from  0.2  to  10  milliamperes. 

The  patient  is  laid  in  bed  with  the  feet  directed  toward  the  observer, 
who  grasps  the  right  foot  with  the  left  hand,  in  such  a  manner  as  to 
be  able  to  detect  the  slightest  response  occurring  in  the  flexor  tendons 
or  the  ankle  or  toes.  The  negative  electrode  is  placed  upon  the  ab- 
domen of  the  patient,  while  the  positive  one  is  controlled  by  the  right 
hand  of  the  operator,  who  at  the  same  time  regulates  the  rheostat  with 
his  elbow.  The  test  should  always  be  begun  with  a  current  strength 
sufficient  to  produce  muscle  response  and  then  gradually  reduced.  If 
the  opposite  is  attempted,  the  lowest  point  will  invariably  be  passed. 
One  should  always  consider  the  individual  skin  resistance,  which  varies 
directly  with  the  amount  of  fat  and  is  rapidly  reduced  as  the  test 
progresses. 

Prognosis. — The  prognosis  depends  entirely  upon  the  condition 
which  accounts  for  the  tetany,  which  is  to  be  looked  upon  as  a  symp- 
tom and  not  a  disease.  The  eclampsia  case,  to  which  I  have  already 
referred,  came  near  a  fatal  termination. 

Fatal  cases  have  been  recorded  as  occurring  with  thj-mus  gland 
involvement,  and  here  again  we  have  enlarged  thymus  as  a  cause  of 
death. 

Treatment. — Inasmuch  as  intestinal  toxemia  and  malnutrition  are 
apparently  important  agencies  in  causing  the  phenomena,  attention 
directed  to  the  intestinal  canal  and  nutrition  is  indicated.  The  child 
should  be  given  2  drams  of  castor  oil,  and  milk  should  be  excluded 
from  the  diet  for  a  day  or  two  until  the  stools  become  normal.  This 
treatment  alone  has  cleared  up  some  of  my  cases.  When  the  spasm 
persists,  bromid  of  soda  should  be  given  in  2-grain  doses  every  two 
hours,  at  least  6  doses  in  twenty-four  hours  being  given  to  a  child  one 
year  of  age  or  younger.  Calcium  bromid  appears  to  be  of  some  service 
in  controlling  the  symptoms  in  5-  or  10-grain  doses  4  times  daily. 

Whether  the  benefit  is  due  to  the  sedative  action  of  the  bromid 
alone  or  the  possibility  that  some  of  the  calcium  given  is  retained  as 
such,  is  an  open  question.  No  satisfactory  metabolic  experiments 
have  been  made  to  show  that  such  retention  takes  place  when  calcium 
is  administered  through  the  alimentary  tract.  No  unpleasant  effect 
has  been  observed  from  the  use  of  the  drug.  In  a  recent  case  there  was 
decided  retention  of  sodium  chlorid.  This  was  relieved  by  free  cathar- 
sis and  the  use  of  urea,  15  grains  daily  in  the  food.  The  child  recovered 
in  two  weeks. 

The  patient  should  be  kept  very  quiet  during  an  attack,  as  undue 
excitement  may  precipitate  an  attack  of  laryngismus  stridulus  or  con- 


INSANITY    IN    CHILDREN  497 

vulsions,  which  may  be  of  a  very  serious  nature.  A  hot  bath  at  110°F. 
for  a  few  moments,  repeated  at  six-hour  intervals,  will  often  have  the 
desired  relaxing  effect. 

The  later  treatment  consists  in  regulating  the  child's  nutrition.  If 
the  malnutrition  is  extreme,  or  if  the  infant  is  under  six  months  of 
age,  a  wet-nurse  affords  the  safest  means  of  nutrition.  A  wet-nurse, 
however,  is  not  practicable  for  children  over  one  year  of  age.  There 
is,  moreover,  considerable  uncertainty  as  to  how  older  infants  ap- 
proaching the  twelfth  month  will  take  the  breast.  "When  emploj^ment 
of  the  wet-nurse  is  impossible  or  impracticable,  an  adjustment  of  the 
food  to  the  child's  digestive  capacity  is  demanded  along  the  lines  laid 
down  in  the  section  on  Malnutrition. 

Proteid  Diet. — Not  a  few  of  the  infants  who  develop  tetany  have 
had  food  poor  in  proteid,  such  as  is  furnished  by  the  proprietary  foods 
and  condensed  milk,  or  they  may  have  had  a  low  proteid  capacity, 
which,  as  far  as  the  nutrition  is  concerned,  amounts  to  practically  the 
same  thing.  The  proteid  elements  in  the  diet,  therefore,  should  be 
kept  well  in  mind  in  feeding  these  cases.  It  is  in  such  cases  that  pep- 
tonized milk  and  malt  soup  (pp.  68  and  94)  are  indicated.  The  milk 
should,  always  be  given  raw,  unless  the  patient's  station  in  life  or  the 
season  of  the  year  forbids.  If  the  milk  is  heated,  as  is  necessary  in 
malt-soup  feeding,  orange  or  beef -juice  should  be  given  at  the  same 
time. 

Climate. — When  possible,  children  who  have  had  tetany  should  in 
every  instance  be  given  the  advantages  furnished  by  climate.  An 
outdoor  life  in  the  country,  with  open  windows  at  night,  is  necessary 
for  rapid  relief  of  the  weakened  physical  condition  which  underlies  the 
disorder. 

Bath  and  Oil  Inunctions. — The  patient  should  be  given  a  brine  bath 
(p.  780)  at  bedtime.  This  is  to  be  followed  by  inunction  with  an  ani- 
mal fat  during  the  cooler  months,  goose-oil  or  fresh  lard  being  preferred. 

Tonics. — As  these  patients  are  usually  suffering  from  a  secondary 
anemia,  '^'2  grain  of  citrate  of  iron  and  ammonium  may  be  given  two 
or  three  times  daily  after  feeding.  The  hygienic  and  dietetic  manage- 
ment of  tetany  is  practically  the  same  as  that  suggested  for  marasmus 
and  malnutrition. 

INSANITY  IN  CHILDREN 

Insanity  in  children,  implying  a  completely  developed  functional 
mental  disorder,  is  very  infrequent.  When  it  occurs,  its  existence  may 
most  frequently  be  traced  to  hereditary  influence.  This  need  not  im- 
ply the  existence  of  actual  insanity  in  the  patient's  ancestors,  but,  in 
many  instances,  only  pronounced  neuropathic  diathesis,  the  effects  of 
which  are  apparent  under  conditions  of  excitement  and  stress.  In  cer- 
tain families  there  may  be  a  gradual  deterioration  of  the  character 
described  by  Kirchoff:  "In  the  first  generation  we  find,  apart  from 
nervous  symptoms,  the  disappearance  of  ethical  feelings;  then  follows 
a  generation  in  which  the  tendency  to  excesses  appears,  and  the  danger 
32 


498  THE  PRACTICE  OF  PEDIATRICS 

is  then  greatly  increased  by  alcoholism.  In  the  third  generation  there 
is  perhaps  suicide,  or  an  affective  form  of  insanity,  and  finally  more 
profound  mental  disorders  appear,  such  as  congenital  idiocy," 

Probably  no  less  important  than  heredity  are  the  environment  and 
the  early  associations  of  the  patient.  A  child's  mental  processes  are 
closely  dependent  on  sensory  impressions  and  the  affections  of  pleasure 
and  pain.  Desires  are  inherent,  but  active  volition  and  self-control 
are  faculties  of  slow  development.  Under  these  conditions  phe- 
nomena, such  as  fright,  illness,  injury,  or  neglect,  exert  a  greatly 
augmented  influence.  The  period  of  puberty,  moreover,  is  responsible 
for  perversions,  emotional  outbreaks,  and  other  manifestations  of 
instability,  which  explain  the  origin  of  a  large  group  of  cases  of 
mental  aberration. 

Thus,  in  any  individual  of  neurotic  temperament  subjected  to  bodily 
suffering,  overwork,  or  mental  strain,  during  the  period  of  growth, 
insanity  may  occur,  and  its  relative  infrequency  can  be  explained  only 
by  the  remarkable  recuperative  possibilities  of  this  period. 

Imperative  Concepts;  Morbid  Fears. — These  constitute  the  sim- 
plest psychic  disorders  of  childhood,  and  are  extremely  common  and 
of  great  diversity,  ranging  from  simple  incapacity  to  resist  the  fasci- 
nation of  deep  water  and  high  places,  to  uncontrollable  fears  of  darkness 
or  open  places  and  crowds  {agoraphohia)  or  lightning  and  storms 
(astraphohia) .  Occasionally  the  child  may  become  overwhelmed  by 
some  impulse  too  great  for  him  to  resist,  and  develop  a  definite  "  craze." 
The  most  common  forms  of  this  are  kleptomania,  pyromania,  and 
dromomania.  Of  these,  the  "running  away"  impulse  is  perhaps 
oftenest  recognized  as  something  for  which  the  subject  is  not  fully 
responsible. 

Neurasthenia  is  much  less  common  in  children  than  in  adults,  but 
may  develop  in  children  of  neurotic  ancestry  amid  any  conditions 
which  produce  mental  or  bodily  fatigue.  Too  long  school  periods, 
excessive  social  demands  at  home,  and  late  hours  are  among  the  most 
common  causes,  especially  in  the  case  of  poorly  developed  children. 
The  usual  symptoms  of  chronic  irritability,  sleeplessness,  and  "moods" 
may  give  way  at  last  to  a  state  of  true  hypochondriasis. 

Hysteria  in  its  more  pronounced  forms  should  be  distinguished 
from  mere  laughing  and  crying  spells,  which  children  frequently  exhibit 
without  complete  loss  of  control.  Nevertheless,  "in  all  hysteric  sub- 
jects," according  to  Sachs,  there  is  "not  so  much  a  direct  lack  of 
power  to  exert  the  will  as  a  tendency  to  exert  it  in  perverse  fashion." 
Occasionally,  after  a  period  of  severe  stress,  a  child  may  develop 
hysteric  mania.  This  occurs  occasionally  in  girls  on  the  establish- 
ment of  menstruation.  In  cases  of  true  hysteria,  sensory  and  motor 
disturbances  are  common,  and  occasionally  hystero-epileptic  attacks 
may  occur. 

Melancholia  is  frequent  in  children,  and  may  assume  a  serious  form, 
characterized  by  the  development  of  suicidal  tendencies. .  In  most 
instances,  however,  the  prognosis  for  recovery  is  good. 


MALFORMATIONS    OF    THE   BRAIN    AND    CORD 


499 


IVTlaiiia  unrelated  to  hysteria  may  be  induced  by  great  excitement, 
fright,  or  febrile  diseases.  The  influence  of  puberty  upon  the  develop- 
ment of  the  condition  in  girls  has  been  noted.  Under  symptomatic 
measures  involving  enforced  rest  and  quiet,  maniacal  cases  in  the  young 
usually  terminate  in  recovery  after  a  few  months. 

Dementia  praecox,  though  not  a  disease  of  childhood,  is  common 
after  the  twelfth  year.  Hebephrenic,  katatonic,  and  paranoid  types 
are  described.  The  frequency  of  a  prodromal  period  marked  only  by 
neurasthenia  and  hypochondriasis  should  be  remembered. 

Treatment. — The  treatment  of  the  psychic  disorders  of  childhood 
is  comparatively  simple.  Under  a  firm  but  quiet  home  regime,  with 
proper  attention  to  existing  physical  defects,  the  milder  cases  of  de- 
rangement ordinarily  respond  favorably.  Punishment  for  the  persist- 
ence of  ideas  and  fears  for  which  the  patient  is  not  directly  accounta- 
ble may  do  great  harm.  Hysteric  symptoms  of  considerable  duration 
may,  however,  yield  readily  to  the  right  sort  of  sensory  or  psychic 
"surprise."  Suggestion  has  a  very  wide  field  in  the  treatment  of 
children. 

In  the  more  severe  forms  of  mania,  isolation,  close  supervision,  rest, 
and  hydrotherapy  afford  good  results. 

A  properly  functionating  digestive  tract  and  a  good  supply  of 
hemoglobin  and  red  corpuscles  are  essential  to  the  preservation  of  a 
normal  mentality  in  any  child,  regardless  of  heredity  or  environment. 

MALFORMATIONS  OF  THE  BRAIN  AND  CORD 

The  various  types 
of  cerebral  malforma- 
tion are  of  develop- 
mental rather  than  of 
clinical  interest. 

Meningocele,  en- 
cephalocele,  and  hy- 
drencephalocele  are 
protrusions  of  cranial 
contents  through  con- 
genital gaps  which  per- 
sist between  the  bones 
of  the  skull.  Such  de- 
fects are  most  com- 
mon in  the  occipital 
and  frontonasal  re- 
gions. 

When  the  protrud-  L. 
ing  sac  consists  only  of 
the     membranes     sur- 
rounding the  brain,  it  is  called  a  meningocele;  when  a  portion  of  the 
brain  itself  is  included,  the  tumor  is  called  an  encephalocele;  and  when 
the  encephalocele  contains  ventricular  fluid  a  hydrencephalocele. 


Alcuiugucele. 


500 


THE    PRACTICE    OF    PEDIATRICS 


In  microcephalus  (see  Fig.  64)  the  capacity  of  the  skull  is  less 
than  normal,  and  the  brain  itself  is  abnormally  small.  This  defective 
development  has  been  explained  by  Virchow's  theory  of  premature 
ossification  in  the  cranial  bones,  but  according  to  Sachs,  is  proba- 
bly due  to  atrophic  changes,  which  are  the  result  of  hemorrhage 
or  inflammation  affecting  the  brain  and  its  membranes.  If  the  latter 
be  the  true  explanation  of  the  deformity,  any  treatment  of  an  operative 
character  to  allow  brain  expansion  by  increasing  the  dimensions  of  the 
skull  must  prornise  little. 

Neither  explanation  is  satisfactory.  There  is  more  than  a  prema- 
ture ossification.  The 
skull  formation  along 
the  line  of  sutures  is 
excessive.  In  many 
cases  I  have  found  at 
the  line  of  the  suture 
a  distinct  ridge,  as 
though  nature  had 
taxed  herself  to  the 
utmost  to  unite  the 
cranial  bones.  The 
ductless  glands  prob- 
ably are  a  factor  in  the 
o  v  e  r-d  evelopment. 
With  the  excessive 
ossification  at  the 
sutures  the  bones  of 
the  skull  generally  are 
much  thicker  than 
normal. 

Symptomatology.  — ■ 
The  symptomatology 
Palsy.      The    patients 


Fig.  64. — Microcephalic  idiot. 


is    the  same    as    described    under    Cerebral 
are  almost  always  low-grade  defectives. 

In  subjects  with  microcephalus — microcephalic  idiots — who  survive 
infancy,  symptoms  of  paralysis,  lack  of  development  of  the  special 
senses,  and  low  intelligence  are  the  rule. 

Craniectomy. — The  operation  of  craniectomy,  based  upon  the 
theory  that  the  condition  is  due  to  a  premature  ossification  of  the 
skull,  was  much  in  vogue  several  years  ago.  It  was  usually  unpro- 
ductive of  beneficial  results,  and  has  been  discarded.  Craniectomy  was 
performed  on  an  imbecile  boy  of  four  years  of  age  who  was  under  my 
care  at  the  New  York  Infant  Asylum.  After  the  operation  he  received 
more  care  and  attention  than  before,  and  he  seemed  to  develop  some- 
what along  mental  lines,  but  when  the  attention  was  later  withheld, 
he  relapsed  into  the  former  condition, 

Porencephalus  is  a  condition  characterized  by  the  existence  of  a 
hole  in  the  brain  substance.     This  abnormality  may  be  congenital  or 


MALFOKMATIONS    OF    THE    BRAIN    AND    CORD  501 

acquired.  The  congenital  form  may  develop  from  atraumatic  enceph- 
alitis during  intra-uterine  life.  The  acquired  form  is  usually  due  to 
meningeal  hemorrhage.  The  cavity  in  porencephalus  commonly  in- 
volves the  motor  areas  of  the  cerebrum  and  extends  into  the  lateral 
ventricle.  According  to  Dana,  true  porencephalus  due  to  a  congenital 
defect  in  nutrition  occurs  in  about  one-fourth  the  cases  of  cerebral 
palsies  in  children. 

Cyclops,  hemicephalus,  anencephalus,  and  malformations  of  in- 
dividual lobes  of  the  brain  belong  to  the  domain  of  embryology  and 
neurology,  rather  than  to  general  pediatrics.  The  terms  themselves 
roughly  define  the  respective  conditions. 

Spina  Bifida. — Spina  bifida  is  the  term  applied  to  a  congenital 
cleft  in  the  vertebral  column  which  permits  of  a  hernia  of  part  of  the 


Fig.  65. — Spina  bifida. 

contents  of  the  canal.     The  defect  is  found  most  frequently  in  the 
cervical  or  lower  lumbar  vertebrae. 

In  meningocele  of  the  cord  the  membranes  alone  constitute  the  hernia 
sac. 

Myelomeningocele  is  a  protrusion  of  a  portion  of  the  spinal  cord  and 
its  attached  nerve-roots,  together  with  an  accumulation  of  fluid,  which 
usually  has  its  origin  in  the  anterior  subarachnoid  space. 

In  syringomyelocele,  hydromyelocele,  or  myelocystocele  the  central 
canal  of  the  cord  is  dilated  with  fluid,  and  the  cord  substance  itself 
forms  the  lining  of  the  sac. 

The  malformations  just  described  are  frequently  accompanied  by 
other  abnormalities  in  the  same  subject,  such  as  hydrocephalus,  club- 
foot, sensory  and  trophic  disturbances  and  exstrophy  of  the  bladder. 
With  myelomeningocele  and  syringomyelocele,  paralysis  of  the  ex- 
tremities, bladder,  and  rectum  may  exist. 

Diagnosis  of  the  type  of  spina  bifida  present  in  a  given  case  is  not 
always  easy. 

Simple  spinal  meningocele  is  frequently  found  in  the  sacral  region. 
This  tumor  is  often  translucent.  It  protrudes  through  a  small  cleft 
in  the  canal  and  is  pedunculated.  It  is  seldom  associated  with  symp- 
toms of  paralysis. 


502  THE    PRACTICE    OF    PEDIATRICS 

In  myelomeningocele  and  syringomyelocele  the  swelling  is  ordi- 
narily less  transparent  and  has  a  broader  base.  Pressure  on  the  tumor 
may  cause  distention  of  the  fontanel.  These  forms  commonly  occur 
in  the  lumbosacral  region,  but  may  exist  in  any  region  of  the  spine. 
Paralytic  symptoms  are  much  more  common  than  in  cases  of 
meningocele. 

Of  the  three  forms,  syringomyelocele  is  far  the  most  frequently 
associated  with  a  hydrocephalus. 

Prognosis. — Simple  meningocele  offers  a  fair  prognosis  under  treat- 
ment. Some  cases  even  terminate  favorably  by  spontaneous  rupture 
of  the  sac  and  closure  of  the  cleft  in  the  spine. 

In  other  instances  operation  may  be  followed  by  complete  recovery, 
although  in  about  one-third  of  the  cases  the  operation  is  followed  by 
an  acute  hydrocephalus. 

In  a  very  recent  case  of  a  child  two  months  of  age  the  beginning  of  hydroceph- 
alus was  apparent  ten  days  after  the  removal  of  the  meningocele. 

The  two  other  forms  of  spina  bifida  are  very  unpromising,  and  under  the  best 
therapeutic  measures  usually  result  fatally. 

Treatment. — The  results  of  treatment  of  spina  bifida,  regardless  of 
its  type  or  the  method  employed,  will  scarcely  warrant  us  in  promising 
parents  much  in  the  way  of  improvement.  In  my  hands  the  injection 
of  iodin  has  not  been  of  any  value.  The  pressure  treatment  is  unsatis- 
factory. Surgery  promises  better  results  than  does  any  other  treat- 
ment. Operative  measures  are  fully  described  in  works  on  surgery, 
and  the  results  are  sometimes  brilliant.  So-called  cured  cases,  how- 
ever, often  develop  internal  hydrocephalus,  so  that  the  latter  condi- 
tion is  worse  than  the  original.  Operations,  further,  are  not  without 
immediate  danger,  for  in  a  great  majority  of  cases  portions  of  the  cord 
are  within  the  sac,  the  excision  of  which  may  result  in  permanent  paraly- 
sis and  deformity.  It  is  the  duty  of  the  physician  to  see  that  the  tumor 
is  carefully  protected  and  kept  clean,  and  that  the  child  is  properly 
nourished  until  such  time  as  a  suitable  operation  is  thought  advisable. 

TYPE  AND  INCIDENCE  OF  BRAIN  TUMOR 

Tuberculous  tumors  are  by  far  the  most  frequent  form  of  intra- 
cranial neoplasms  occurring  in  childhood.  More  than  50  per  cent,  of 
all  brain  growths  belong  to  this  type.  Next  in  order  of  frequency  are 
gliomata,  gliosarcomata,  and  sarcomata,  while  adenomata,  fibromata, 
angiosarcomata,  cholesteomata,  and  gummata  are  all  rare  in  children, 
carcinomata  being  exceedingly  rare. 

Cysts  of  the  brain  resulting  from  an  old  hemorrhage  or  from  emboUc 
softening  may  simulate  the  symptoms  of  a  growing  neoplasm  if  the 
cyst  contents  become  suddenly  increased.  Parasitic  cysts  of  the 
brain  (echinococcus  or  cysticercus)  are  not  unknown  in  children. 

Brain  tumors  may  be  congenital,  or  they  may  develop  at  any  time 
after  birth.  Gowers  observed  18.5  per  cent,  in  the  first  ten  years  and 
14  per  cent,  in  the  second  decade  of  life. 


MONGOLIAN   IDIOCY  503 

MENTALLY  DEFICIENT  CHILDREN  (IMBECILITY;  IDIOCY) 

It  is  not  desirable,  even  were  it  possible,  to  make  a  differentiation 
of  the  various  types  of  mentally  defective  children.  Mongolian  idioc}^ 
cretinism,  and  amaurotic  family  idiocy  are  distinctive  types,  each 
type  having  characteristics  of  its  own  sufficient  to  demand  a  distinct 
classification.  All  other  forms  are  so  variable  in  their  etiology  and 
the  degree  of  impairment  which  they  produce  that  any  separate  group- 
ing is  impossible.  Thus  we  see  idiocy  due  to  microcephalus  (see  Fig. 
64),  to  hydrocephalus,  to  antenatal  defects,  to  birth  trauma,  and  to 
meningitis,  particularly  of  the  cerebrospinal  form. 

Besides  microcephalic,  hydrocephalic,  Mongolian,  amaurotic  family, 
and  cretinoid  idiocy,  there  is  a  form  of  idiocy  in  which  the  brain  shows 
sclerotic  areas  in  the  cortex.  These  may  be  due  to  hemorrhage  at 
birth.  Cerebrospinal  meningitis  complicated  by  encephalitis  may  also 
be  responsible  for  the  sclerosis.  Finally  there  may  be  porencephalus,  a 
smaller  or  larger  defect  in  a  cerebral  hemisphere,  either  of  congenital 
origin  or  due  to  hemorrhage  at  birth  or  later. 

Unclassified  Cases. — Epilepsy  in  early  life  tends  to  mental  im- 
pairment, and  may  eventually  result  in  idiocy.  I  have  repeatedly 
seen  cases  in  which  no  cause  whatsoever  could  be  demonstrated  to 
explain  the  condition. 

The  brain,  although  a  most  important  organ,  is  very  ineffectively 
protected  until  the  child  is  well  on  in  the  third  year.  If  the  facts  in 
each  case  were  known,  it  would  probably  be  discovered  that  brain 
trauma  at  birth  was  the  cause  of  idiocy  in  a  large  majority  of  the  un- 
classified cases.  Syphilis,  consanguineous  marriages,  and  alcoholism 
are  looked  upon  as  etiologic  factors  by  many  authors.  The  mental 
improvement  varies  within  wide  hmits,  and  the  cases  range  from  those 
of  complete  idiocy  to  those  in  which  it  is  impossible  to  determine 
whether  the  patient  is  within  or  without  the  group  which  is  looked 
upon  as  normal.  Mental  impairment  is  often  associated  with  spastic 
paralysis;  the  majority  of  the  unclassified  cases  show  such  association. 
Nevertheless,  in  the  examination  of  hundreds  of  cases  in  institutions, 
many  defectives  will  be  found  in  whom  there  is  no  evidence  of  muscle 
involvement. 

Mentally  defective  children  are  described  as  backward,  feeble- 
minded, children  of  retarded  development,  imbeciles,  and  idiots.  In 
a  legal  sense  all  are  imbeciles  who  cannot  appreciate  right  and  wrong. 
Idiots  show  complete  absence  of  responsibility. 

Defective  sight  and  hearing  may  place  a  child,  naturally  not  men- 
tally keen,  in  the  defective  class. 

MONGOLIAN  IDIOCY 

The  Mongolian  type  (Figs.  66,  67,  and  68)  is  found  with  very  few 
exceptions  only  in  the  Caucasian  race,  and  received  its  designation 
because  of  the  facial  resemblance  to  the  Mongolian. 

Etiology. — Mongolianism  is  of  congenital  origin.  There  is  no  known 
cause.     Debility  in  parents  seems  to  play  an  important  part.     They 


504  THE  PRACTICE  OF  PEDIATRICS 

are  found  among  the  first  born  of  old  parents,  the  first  born  of  very 
young  parents.  They  are  apt  to  represent  the  5th,  6th  or  7th  preg- 
nancy. They  may  also  be  the  1st  or  2d  pregnancy  of  perfectly 
normal  parents.  This,  however,  is  unusual.  In  these  cases,  as  in 
cretinism,  it  will  probably  be  discovered  in  the  future  that  we  are 
deahng  with  a  ductless  gland  defection.  Whatever  may  be  the 
cause,  it  is  identical  in  all,  for  all  Mongols  are  alike  in  form,  feature, 
intelligence  and  the  many  characteristics  that  go  to  form  the  symptom 
complex  of  Mongolism;  this  regardless  of  race,  social  position,  age  or 
physical  condition  of  the  parents.  Whatever  may  be  the  basic 
error,  it  is  the  same  in  all  and  it  is  not  due  to  syphilis. 

Pathology. — Besides  the  Mongolian  type  of  face,  the  microcephalic 
skull  and  the  retarded  bone  growth  are  characteristic  of  the  disease. 

Mongolian  idiots  at  autopsy  show 
'the  evidence  of  faulty  development 
of  the  brain  cortex.  The  entire 
brain  is  smaller  and  lighter  in  weight 
than  is  normal,  and  fissuration  is 
defective.  Congenital  cardiac  mal- 
formation is  not  infrequent  in  these 
cases,  a  patent  ductus  arteriosus  or 
an  incomplete  ventricular  septum 
being  the  commonest  lesions  found. 
Other  visceral  malformations  occur 
less  frequently,  but  stigmata  of  de- 
generation are  very  numerous, 
especially  of  the  palate,  ears,  and 
fingers. 
66.— Mongolian  idiocy.  Symptomatology.— The  ^  face     is 

usually  defective  in  expression,  broad 
and  flat,  the  nose  small  and  broad  at  the  base,  the  eyes  wider  apart  than 
in  the  normal  child.  In  rare  cases,  the  face  will  show  a  considerable 
degree  of  intelligence  (Fig.  67),  and  is  usually  round  and  full.  The 
eyes  are  prominent  and  placed  obliquely,  with  the  palpebral  fissures 
extending  in  an  upward  direction,  elevating  the  outer  canthus.  The 
skull  shows  anteroposterior  narrowing,  which,  together  with  the  promi- 
nence of  the  upper  cervical  vertebra,  causes  a  marked  narrowing  of  the 
nasopharyngeal  vault.  This  is  readily  appreciated  on  examining  the 
subject  for  adenoids,  which  are  supposed  to,  exist  because  of  the  habit 
of  the  open  mouth  and  mouth-breathing.  The  tongue  is  usually  large, 
and  protrudes  during  a  greater  part  of  the  time.  The  muscles  of  the 
arms  and  legs  are  soft,  the  skin  is  usually  rather  dry  and  bluish,  and 
there  is  a  tendency  to  coldness  of  the  extremities.  The  joints  are  re- 
laxed and  the  ears  are  crumpled.  There  is  a  distinct  inward  curve  of 
little  fingers  particularly  of  the  third  phalanx.  The  occiput  is  flat. 
The  children  have  a  vacant,  stupid  expression,  and  are  unusually  good- 
natured.  They  cry  much  less  than  normal  children.  They  are  feeble, 
and  a  great  majority  die  before  they  are  three  years  of  age.     They  are 


MONGOLIAN    IDIOCY 


505 


particularly  subject  to  respiratory  and  intestinal  diseases.  A  few  grow 
to  adult  life.  In  an  institution  for  the  feeble-minded  there  are  but  two 
Mongols  in  300  inmates,  all  over  eight  years  of  age.  I  know  two  grow- 
ing children,  distinct  Mongols,  who  possess  a  fair  degree  of  intelligence. 
Such  instances,  however,  are  very  exceptional.  Development  is 
generally  delayed,  the  teeth  appear  late,  and  what  speech  ability  is 
attained  is  aquired  only  after  the  child  is  four  or  five  years  of  age. 

Diagnosis. — It  is  difficult  to  understand  why  so  many  of  these  cases 
fail  of  diagnosis.     The  patients  are  not  at  all  like  normal  children  and 


Fig.   67. — Mongolian  idiot. 


may  only  be  confused  with  cretins.     (For  differential  diagnosis  see 
Cretinism,  p.  727.) 

Treatment  of  the  Mentally  Defective. — The  mental  defectives,  with 
the  exception  of  the  cretin,  the  amaurotic  family  idiot  and  the  spastic 
paralytic,  lend  themselves  to  one  scheme  or  method  of  treatment,  wliich 
is  to  be  considered  from  two  standpoints:  first,  that  of  attention 
to  the  physical  condition;  secondly,  that  of  attention  to  the  mental  con- 
dition. Under  the  first  heading  are  included  the  correction  of  de- 
formities and  the  management  as  relates  to  hygiene  and  nutrition,  both 
of  which  should  be  the  best  obtainable  in  any  given  case.  The  second 
consideration,  relating  to  the  mental  aspect  of  the  case,  concerns  not 
only  the  patient  but  the  family  and  their  immediate  interests. 


506 


THE    PRACTICE    OF    PEDIATRICS 


Institutions. — Almost  without  exception  the  place  for  a  mentally 
defective  child  is  in  an  institution  which  is  devoted  to  the  care  and 
teaching  of  such  children.  The  defective  should  be  placed  where  much 
will  not  be  expected,  where  he  will  be  associated  with  others  of  his 
kind,  where  his  work  and  his  play  will  be  adjusted  and  presided  over  by 
educated  men  and  women  who  have  made  such  conditions  the  study  of 
their  lives.  The  defective  has  his  rights.  He  has  a  right  to  live  out  his 
unfortunate  life  in  as  pleasant  a  manner  as  possible,  and  this  is  better 
accomplished  in  an  institution  than  in  any  individual  home.  In  an 
institution,  among  other  things,  such  patients  are  taught,  according 

to  their  capacity,  useful 
occupations.  Not  a  few 
thus  taught  become  self- 
supporting.  At  rare  in- 
tervals one  is  found  who 
possesses  remarkable 
mental  traits  along  cer- 
tain lines,  traits  which 
the  average  normal  in- 
dividual is  incapable  of 
understanding.  I  have 
one  such  case  under  my 
care.  Patients  showing 
a  moderate  degree  of 
infirmity  often  become 
skilled  in  handicraft. 
They  execute  mechan- 
ically with  surprising  ac- 
curacy. There  have 
been  great  geniuses  of  the  past  who  in  some  respects  were  not  con- 
sidered mentally  normal  by  their  contemporaries.  It  is  impossible  to 
form  even  a  fair  estimate  as  to  how  the  mentally  defective  child 
will  develop,  with  age,  and  suitable  instruction  from  those  who  are 
best  able  to  discover  his  possibilities. 

Placing  these  children  in  public  institutions  is  often  strenuously 
objected  to  on  sentimental  grounds  by  the  poorer  members  of  society 
because  of  their  fears  and  prejudices  against  such  institutions.  In 
consequence,  many  a  child  is  kept  at  home,  greatly  to  his  detriment  and 
to  the  decided  injury  of  other  children  in  the  family.  Time  and  again 
I  have  pleaded  with  the  mothers  and  fathers  of  such  children  without 
avail.  Few  villages  throughout  the  country  do  not  have  an  idiot  or  an 
idiotic  epileptic  for  school-boys  to  taunt  and  for  school-girls  to  fear. 
Most  pitiable  objects  are  these  human  derelicts,  with  whom  the  State 
does  not  interfere  because  they  are  "harmless."  Sooner  or  later,  if  he 
lives,  the  idiot  of  poor  parentage  will  become  a  public  charge,  and  the 
better  his  condition  at  the  time,  the  happier  he  will  be. 

Parents  of  means  and  intelligence  will  usually  place  such  a  child  in 
one  of  the  many  private  institutions  that  are  conducted  for  the  care  of 


Fig. 


68. — Mongolian    idiot,    showing    advanced 
malnutrition   (five  months). 


AMAUROTIC    FAMILY    IDIOCY  507 

defectives;  but  the  objection  will  often  be  raised,  even  by  these  parents, 
that  such  children  have  so  little  mentality  that  teaching  is  useless. 
This  may  be  true,  but  on  this  very  account,  if  for  no  other  reason,  the 
child  should  be  removed  from  the  home  because  of  his  invariably  per- 
nicious influence  on  other  members  of  the  family. 

The  vicious,  the  unclean,  and  those  showing  marked  moral  degen- 
eracy should  be  placed  in  institutions  as  soon  after  the  fourth  year  as 
possible.  If  they  are  to  be  a  public  charge,  they  should  be  removed 
from  the  home  as  soon  as  they  arrive  at  the  age  limit  which  the  rules 
of  the  institution  require  for  admission.  A  patient  who  is  tractable 
may  remain  at  home  until  the  sixth  or  seventh  year,  particularly  if  there 
are  no  other  children  in  the  family.  If  there  are  in  the  family  younger 
children,  whose  natural  tendencies  and  powers  of  imitation  are  always 
strong,  the  defective  child  should  be  removed  as  early  as  possible.. 

AMAUROTIC  FAMILY  IDIOCY 

Amaurotic  family  idiocy  is  the  name  given  by  Sachs,*  of  New  York, 
to  a  very  peculiar  disease  of  infancy,  first  described  by  Warren  Tay 
in  1881,  It  is  characterized  by  an  impairment  of  the  muscle  functions, 
volitional  movements  being  at  first  difficult  and  later  impossible,  the 
changes  being  of  a  progressive  type.  Defective  vision  and  mental 
dulness  appearing  in  a  normal  child  are  among  the  early  signs.  The 
disease  progresses  to  complete  idiocy  and  blindness.  (See  Figs.  69 
and  70.) 

Etiology. — The  etiology  of  this  form  of  idiocy  is  unknown.  It  oc- 
curs with  considerable  regularity  in  Hebrews.  Different  children  in 
the  same  family  may  be  affected.  The  disease,  together  with  many 
others  whose  origin  is  not  understood,  has  been  attributed  to  syphilis 
and  alcohol.  The  pathologic  findings  prove  the  disease  to  be  due  to  a 
toxemia  which  slowly  but  persistently  attacks  and  entirely  destroys, 
through  degenerative  processes,  whatever  is  vital  in  the  entire  nervous 
system. 

Pathology. — Consistence  is  again  shown  in  the  lesions  of  the  disease, 
which,  wherever  present,  are  invariably  the  same. 

Hirsch's  early  findings  have  been  corroborated  by  many  others, 
showing  that  there  is  a  degeneration  of  the  ganglion  cells  throughout 
the  entire  nervous  system.  If  we  are  to  believe  these  investigations, 
there  is  not  a  normal  cell  left  either  in  the  cortex  or  the  gray  matter  of 
the  cord. 

The  cell  protoplasm  undergoes  degeneration,  the  nucleus  is  demon- 
strable with  difficulty  and  becomes  a  part  of  the  degenerated  cell. 
Later  changes  cause  an  entire  loss  of  cell  structure  and  render  it  diffi- 
cult to  determine  the  cell  contour. 

The  ganglion-cells  of  the  retina  and  the  fibers  of  the  optic  nerves 
and  tracts  are  degenerated,  this  fact  accounting  for  the  blindness. 
Degeneration  of  the  white  fibers  of  the  anterior  and  lateral  pyramidal 
*  Sachs'  Nervous  Disorders  of  Children,  p.  462. 


508 


THE    PRACTICE    OF    PEDIATRICS 


tracts  has  been  described  by  Shaffer.  Sachs  is  of  the  opinion  that  these 
are  secondary  changes. 

The  thoracic  and  abdominal  viscera  show  no  specific  lesions. 

Symptoms. — The  history  is  usually  that  of  a  child  born  well  and 
who  remained  in  a  normal  condition  until  he  was  five  or  six,  or  perhaps 
nine,  months  old.     He  then   became  inactive,  listless,  and  failed  to 


Fig.  69. — Amaurotic    idiocy.     (Early    stage.) 

follow  objects  or  persons  with  the  eyes.  In  all  probability  the  sight  is 
impaired  much  earlier  than  is  supposed,  as  in  the  four  cases  which  I 
have  had  the  opportunity  to  examine  blindness  was  present  early  in 
the  disease.  A  marked  degree  of  visual  impairment  as  well  as  men- 
tal apathy  will  pass  unobserved  in  many  of  the  homes  of  the  class 
who  supply  the  amaurotic  idiot.     The  eyes  assume  a  peculiar  fixed 


Fig.  70. — Amaurotic  idiocy.     Same  case.     (Late  stage.) 

stare  fairly  early  in  the  disease,  not  unlike  that  of  the  later  stage 
of  meningitis.  The  child  not  only  shows  apathy  and  indifference,  but 
is  soon  unable  to  sit  up  or  support  the  head,  which  falls  in  any  direc- 
tion in  response  to  the  force  of  gravity.  As  the  case  progresses  the 
patient  loses  all  power — even  the  power  of  changing  the  position  of  a 
limb.     With  the  mental,  visual,  and  muscle  impairment,  there  is  in- 


HYDROCEPHALUS  509 

variably  progressive  emaciation.  Convulsions  and  nystagmus  may  be 
present  but  are  not  characteristic  symptoms. 

Fairly  early  in  the  disease  there  is  an  unusual  susceptibility  to  sound ; 
clapping  the  hands  or  any  inconsiderable  noise  causes  the  child  to  start 
violently.  The  reflexes  vary  at  different  periods  and  are  variable  and 
unreliable.  Toward  the  end  the  respiration  becomes  very  superficial, 
swallowing  is  impossible,  and  the  child  must  be  fed  by  gavage.  When 
death  occurs,  the  child  presents  the  picture  of  marked  inanition. 

Course  and  Prognosis. — The  onset  of  the  disease  is  very  gradual. 
Its  course  is  slow,  with  the  evidence  of  progressive  degeneration.  The 
outcome  is  invariably  fatal.  A  not  uninteresting  feature  of  the  cases 
is  their  similarity.  They  occur  in  the  same  race  of  people.  The  onset, 
course,  and  termination  are  alike,  even  to  the  time  required  for  the  dis- 
ease to  run  its  course.  There  is  almost  a  mathematical  succession  of 
events. 

Diagnosis. — The  disease  is  sometimes  mistaken  for  meningitis. 
Other  cases  have  been  mistaken  for  those  of  birth-palsy.  Even  if  there 
should  be  occasion  for  confusion  because  of  the  similarity  of  symptoms, 
which  is  very  slight,  the  examination  of  the  eye-grounds,  which  should 
be  undertaken  in  every  case  in  which  there  is  a  suspicion  of  cerebral  in- 
volvement, renders  the  differentiation  possible  through  the  presence  or 
absence  of  ''symmetric  changes  in  the  region  of  the  yellow  spot  in  each 
eye  of  an  infant ' '  (Tay) .  This  lesion  Tay  and  Kingdon  have  designated 
as  the  "cherry  red  spot."  The  presence  of  this  sign  makes  the 
diagnosis  in  a  suspected  case  positive,  proving  the  presence  of  optic 
nerve  atrophy. 

Treatment. — Treatment  is  of  no  avail.  Our  best  efforts  for  these 
patients  are  to  be  exerted  in  maintaining  nutrition  and  in  ministering 
to  their  comfort. 

HYDROCEPHALUS 

By  hydrocephalus  is  understood  an  excessive  amount  of  fluid  within 
the  skull.  This  fluid  may  be  either  within  the  brain,  in  the  ventricles 
(internal  hydrocephalus),  or  it  may  be  external  to  the  lesion,  existing 
as  an  effusion  into  the  subarachnoid  space  (external  hydrocephalus). 
Further  differentiation  is  made  into  the  acute  and  chronic,  congenital 
and  acquired,  types.  A  fault  in  our  nomenclature  is  that  there  is  too 
much  of  it.  It  is  a  question  whether  a  differentiation  into  the  acute  and 
acquired  types  is  possible,  for  no  one  can  state  that  in  the  cases  which 
develop  late — the  so-called  acquired  cases — there  was  not  an  excessive 
effusion  at  birth.  In  fact,  acquired  internal  hydrocephalus  is  an  ex- 
ceedingly rare  condition.  When  it 'occurs,  it  is  usually  the  result  of 
some  mechanical  venous  obstruction.  It  is  very  common  in  cases 
of  meningitis,  due  to  inflammatory  material  closing  the  foramen  of 
Magendie.     The  aqueduct  of  Sylvius  may  also  be  occluded. 

Sachs*  states  that  the  most  common  form  of  obstruction  is  that  due 
to  tumor  in  the  posterior  fossa.  Through  such  obstruction  the  foramen 
*  Nervous  Diseases  of  Children. 


510  THE    PRACTICE    OF    PEDIATRICS 

of  Magendie  may  become  occluded,  and  dilatation  of  the  third  ventricle 
result.  Inflammatory  processes  may  cause  a  closure  of  the  communi- 
cating channels  between  the  ventricles  and  cause  a  hydrocephalus. 
The  amount  of  fluid  in  the  acquired  cases  is  usually  small. 

Congenital  Hydj'ocephalus. — I  have  seen  a  large  number  of  these 
cases,  and  have  made  frequent  autopsies  upon  hydrocephalus  subjects. 
An  excessive  accumulation  of  fluid  develops  in  the  cranial  cavities  during 
intra-uterine  life,  which  has  been  attributed  to  many  causes,  among 
which  syphilis  and  alcoholism  are  frequently  mentioned.  My  own  ex- 
perience is  in  accord  with  that  of  many  other  observers,  in  that  no 
satisfactory  explanation  for  the  condition  has  been  found. 

Congenital  hydrocephalus  is  essentially  chronic.  It  is  an  internal 
hydrocephalus,  that  form  of  the  disease  which  is  usually  seen,  and  the 
condition  referred  to  when  the  term  hydrocephalus  is  used  without 
qualification.  The  head  may  reach  an  enormous  size.  Holt  reports 
a  case  in  which  five  pints  of  fluids  were  found  at  the  autopsy.  In  one 
case  seen  by  me  there  were  three  pints;  the  usual  amount  is  from  one- 
half  to  two  pints. 

The  fluid  is  clear,  and  contains  the  chlorid  of  potassium  and  soda, 
cholesterin,  a  trace  of  albumin,  and  sometimes  urea.  As  a  result  of 
the  pressure  exerted,  the  brain  substance  becomes  thinned  to  a  mere 
shell.  The  convolutions  are  entirely  obliterated.  Removal  intact  of 
what  is  left  of  the  brain  may  be  impossible  after  the  withdrawal  of  the 
fluid,  owing  to  the  fact  that  what  remains  of  the  brain  tissue  falls 
together  in  a  broken  mass. 

The  ependyma  may  be  normal  or  thickened  and  infiltrated. 

Chronic  external  hydrocephalus  is  of  rare  occurrence.  When  present 
it  will  be  found  associated  in  nearly  all  cases  with  a  pachymeningitis. 
The  congenital  form  of  external  hydrocephalus  is  exceedingly  rare. 
Very  few  authentic  cases  have  been  reported. 

Internal  hydrocephalus  (acute)  is  of  infectious  origin.  Any  of  the 
pathogenic  bacteria  may  be  operative,  and  the  symptoms  that  are 
presented  are  those  of  pressure,  seen  in  the  various  forms  of  meningitis. 

Symptoms. — In  a  case  of  the  usual  type, — the  congenital, — which 
develops  into  chronic  hydrocephalus,  it  is  noticed  at  birth  that  the 
child's  head  is  large.  During  the  following  week  it  is  apparent  that 
the  head  is  increasing  out  of  proportion  to  the  remainder  of  the 
body.  The  skull  enlarges  symmetrically  out  of  proportion  to  the  face 
(Fig.  71).  There  are  bulging  of  the  fontanel  and  separation  of  the 
sutures.  The  blue  veins  of  the  scalp  become  enlarged  and  promi- 
nently outlined  in  the  pale  skin.  The  head  may  reach  an  enormous 
size.  In  one  of  my  cases  the  circumference  was  28  inches  at  the  time 
of  death — the  ninth  month.  The  infant  in  advanced  cases  is  not  able 
to  hold  up  the  head.  He  is  dull  and  stupid,  cries  when  disturbed,  and 
takes  food  often  with  indifference.  The  facial  aspect  is  characteristic 
— triangular,  pinched,  and  pale.  The  eyes  take  on  a  peculiar  stare 
and  are  directed  downward,  showing  considerable  paling  of  the  sclera 
above,  and  never  below.     There  is  usually  convergent  strabismus,  and 


HYDROCEPHALUS 


511 


there  may  be  nystagmus.  I  have  observed  the  latter  in  quite  a  number 
of  cases. 

Malnutrition  is  always  present.  Dentition  is  delayed.  The  hair 
is  scanty  and  coarse.     Resistance  is  of  a  very  low  order. 

Nervous  manifestations,  relating  to  the  extremities,  are  not  neces- 
sarily present.  I  have  repeatedly  been  surprised  to  note  this  feature 
of  the  disease.  Some  patients  will  show  a  moderate  degree  of  spastic 
muscular  contraction.  The  hands  may  be  clinched  and  the  feet  ex- 
tended. In  others  no  nervous  manifestations  whatever  will  be  referable 
to  the  extremities. 


r^-  :    • 

i^J^ 

1 

I 

1 

r 
i 

Fig.  71. — Internal    chronic   hydrocephalus. 

Duration. — The  child  rarely  lives  to  the  twelfth  month.  Intercur- 
rent disease,  usually  a  bronchopneumonia  or  an  intestinal  infection, 
terminates  the  case. 

The  above  is  a  description  of  hydrocephalus  as  usually  encountered. 
The  course  and  outcome,  however,  are  not  always  the  same.  The  proc- 
ess may  be  arrested  at  any  time.  I  have  seen  a  few  such  cases.  The 
enlargement  of  the  cranium  in  these  patients  is  slower,  and  noticeable 
enlargement  may  not  occur  until  the  fifth  or  sixth  month  is  reached. 

Illustrative  Cases. — A  private  female  patient  had  suffered  from  digestive  dis- 
turbance and  moderate  malnutrition  in  the  early  months.  She  improved  satis- 
factorily, so  that  an  interval  of  six  weeks  elapsed  without  my  seeing  her.     When 


512  THE    PRACTICE    OF    PEDIATRICS 

she  was  five  months  old  I  had  occasion  to  readjust  her  food,  and  was  astounded  to 
note  the  change  in  the  size  of  the  child's  head.  It  showed  the  characteristic 
globular  form,  the  high  forehead,  and  large  fontanel,  but  there  was  no  separation 
of  the  sutures.  The  circumference  was  17  inches.  Squint  or  nystagmus  was  not 
present,  and  the  child  supported  the  head  well.  During  the  next  two  months  the 
head  increased  in  size  three  inches.  It  remained  at  20  inches  for  four  months. 
The  child  is  now  six  years  of  age  and  is  normal  in  all  respects. 

Another  female  patient  first  came  when  she  was  one  year  old.  The  mother 
thought  that  the  head  had  been  growing  out  of  proportion  to  the  body  for  a  few 
months.  The  growth  continued  until  the  child  was  two  years  old,  at  which  time 
the  circumference  of  the  head  was  22  inches.  The  patient  was  last  seen  when  six 
years  of  age.  The  mother  considered  the  child  mentally  normal,  although  we  were 
not  convinced  that  such  was  the  case. 

Cases  such  as  the  foregoing  are  those  which  are  reported  as  cured 
from  time  to  time  by  various  methods  of  treatment.  Further,  they 
might  be  looked  upon  as  belonging  to  the  so-called  acquired  type. 
Such  cases  demonstrate  that  there  may  be  a  hydrocephalic  process 
quite  active  in  character  which  subsides  of  its  own  accord,  as  no  treat- 
ment was  given  these  patients  except  proper  food  and  suitable  general 
care. 

Many  authors  maintain  that  cured  hydrocephalus  is  not  at  all  un- 
usual. Sachs  states  that  the  protruding  occipital  bone,  clearly  visible 
on  so  many  bald  heads,  points  to  a  moderate  amount  of  internal  hy- 
drocephalus in  the  early  years  of  life. 

Prognosis. — The  prognosis  is  decidedly  unfavorable  in  those  cases 
in  which  the  hydrocephalus  is  present  at  birth.  Practically  all  such 
patients  die  before  the  tenth  month.  Occasionally  one  will  live  to  be 
over  one  year  old.  In  the  cases  of  slower  or  possibly  later  development 
there  is  a  possibility  of  spontaneous  cure. 

Diagnosis. — The  diagnosis  is  not  difficult.  There  is  an  enlarge- 
ment of  the  cranium,  which  is  fairly  evenly  distended  in  all  directions. 
The  fontanel  is  enlarged  and  pulsating,  and  the  sutures  are  widened. 

The  rachitic  and  the  hydrocephalic  head  are  frequently  confused. 
In  hydrocephalus  the  veins  of  the  scalp  are  distended,  and  nystagmus 
and  squint  are  present.  Early  in  the  case,  if  doubt  is  felt  as  to  the 
nature  of  the  trouble,  weekly  measurements  of  the  skull  will  determine 
whether  or  not  there  is  an  excessive  growth. 

At  birth  the  head  of  the  average  male  is  14  inches  in  circumference; 
that  of  the  female,  133-^  inches.  At  one  year  the  cranium  has  increased 
to  18  inches  in  boys  and  to  173=-^  inches  in  girls. 

At  the  age  of  two  years  the  head  of  the  average  male  measures  19 
inches,  and  that  of  the  female,  183^^  inches. 

Treatment. — No  treatment  at  the  present  time  will  cure  hydrocepha- 
lus. The  cases  that  recover  may  have  been  influenced  by  suitable 
feeding  and  unusual  cure ;  and  drugs  which  may  have  the  effect  of  pro- 
ducing a  better  body  upbuilding  may  have  some  influence  on  the  dis- 
ease, but  of  this  we  are  not  positive.  Many  measures  of  many  kinds — 
medical,  dietetic,  manipulation,  and  operative — have  been  attempted 
by  hundreds  of  physicians. 

lodid  of  potash  and  mercury  have  been  extensively  used.  Hydro- 
cephalic heads  have  been  bound  in  elastic,  which  compressed  the  brain 


CEREBRAL    PALSIES  513 

tissue  all  the  more.     The  ventricles  of  the  brain  and  the  cerebrospinal 
canal  have  been  tapped  and  drained  by  various  methods. 

No  operative  procedure  up  to  the  present  time  has  proved  of  any 
permanent  value. 

CEREBRAL  PALSIES 

Three  forms  of  this  affection  are  recognized — the  prenatal,  the  birth, 
and  the  postnatal  or  acquired  palsies. 

The  Prenatal  and  Birth  Forms 

Etiology. — Concerning  the  etiology  of  the  prenatal  cases,  consider- 
able confusion  and  varying  opinions  exist.  Degeneracy  of  the  parents, 
alcoholism,  syphilis,  and  trauma  are  supposed  to  be  contributory 
causes.  I  have  seen  a  large  number  of  undoubted  prenatal  cases,  and 
am  unable  to  add  anything  from  the  etiologic  standpoint.  In  several 
instances  the  patients  have  belonged  to  families  in  which  there  were 
several  other  children,  all  normal,  with  nothing  worthy  of  note  in  the 
family  history,  and  a  record  of  a  normal,  uneventful  pregnancy  pre- 
ceding the  birth  of  the  patient. 

Trauma  at  birth,  whether  due  to  the  use  of  forceps  or  to  compres- 
sion of  the  head  in  a  prolonged  or  abnormal  delivery,  may  result  in 
meningeal  hemorrhages,  causing  cerebral  palsy.  An  immense  number 
of  cases  are  thus  caused.  The  obstetrician  should  always  keep  in  mind 
that  with  him  rests  the  possibility  of  making  a  hopeless  invalid  or  an 
idiot  of  the  child  he  is  about  to  deliver.  It  is  fully  appreciated  that 
under  unusual  conditions  in  obstetric  practice  certain  risks  of  head 
injury  must  be  taken  for  the  sake  of  the  immediate  demands  of  the 
mother  or  the  child,  but  the  large  number  of  cases  of  cerebral  palsy 
and  idiocy  which  I  have  seen  have  impressed  upon  me  the  necessity 
of  treating  the  child's  head  during  delivery  with  the  utmost  care. 

Lesions. — The  prenatal  and  birth  palsies  are  often  paraplegias  or 
diplegias,  and  as  such  show  a  great  variety  of  lesions. 

In  the  prenatal  cases  there  is  often  failure  of  development  of  a  por- 
tion of,  or  an  entire  hemisphere.  Cysts  are  sometimes  found  at  au- 
topsy. In  other  cases  there  will  be  no  visible  change  to  the  naked  eye. 
Microscopic  examination  of  the  brain  tissue  shows  a  lack  of  develop- 
ment of  the  cells  in  the  motor  areas.  In  the  cases  due  to  trauma  at 
birth  the  results  of  the  early  hemorrhage  will  be  found.  The  most  usual 
changes  are  sclerosis  and  atrophy. 

In  general,  the  lesions  of  cerebral  palsy  include  meningeal  and 
cerebral  hemorrhages,  thrombosis  and  emboHsm,  meningitis  and 
encephalitis,  direct  injury,  tumors,  atrophy,  sclerosis,  and  cyst  forma- 
tion. 

Atrophy,  sclerosis,  and  cysts  are  the  conditions  most  frequently 
observed  at  autopsies.  Such  changes  are  apparently  secondary,  and 
may  generally  be  ascribed  to  previous  embolism,  thrombosis,  hemor- 
rhage, or  encephalitis. 

Meningeal  hemorrhage  is  much  more  common  than  hemorrhage 
33 


514  THE    PRACTICE    OF    PEDIATRICS 

from  a  cerebral  vessel.  Endarteritis  and  pachymeningitis  are  predis- 
posing causes,  and  direct  trauma  and  the  local  congestion  incident  to 
convulsions  or  spasms  of  coughing  are  exciting  causes  of  such  hemor- 
rhage. 

Thrombosis  and  embolism  are  rare  in  children,  but  may  occur. 
Thrombosis  is  sometimes  found  in  cases  of  marasmus,  and  in  other 
instances  may  be  ascribed  to  syphilitic  endarteritis.  Emboli  are,  as  a 
rule,  of  cardiac  origin,  and  lodge  in  a  branch  of  the  middle  cerebral 
artery.     Embolism  may  occur  in  the  course  of  acute  infectious  fevers. 

Encephalitis  may  result  from  an  acute  infection  or  from  trauma. 
Acute  polio-encephalitis  as  a  cause  of  palsy,  is  well  recognized.  Ac- 
cording to  Cautley,  three-fourths  of  the  cases  of  acquired  cerebral 
paralysis  in  children  develop  before  the  fourth  year. 

Sachs  states  that,  prior  to  autopsy  in  a  case  of  acute  cerebral  palsy 
of  several  years'  duration,  it  is  impossible  to  predict  what  type  of 
secondary  brain  lesion  will  be  found.  When  the  symptoms  have  been 
well  defined  and  focal,  and  associated  with  little  idiocy,  he  has  in  sev- 
eral instances  correctly  diagnosed  the  presence  of  cysts.  IdioQy  and 
epilepsy,  associated  with  cerebral  palsy,  are  symptoms  which  he  attri- 
butes chiefly  to  sclerosis. 

Symptoms. — Hemiplegia  is  rare  except  in  the  acquired  cases.  In 
the  prenatal  cases,  and  those  due  to  injury  at  birth,  which  latter  con- 
stitute by  far  the  majority,  there  is  frequently  a  diplegia  or  paraplegia. 
The  first  symptom  of  trouble  in  these  cases  is  usually  that  of  spasticity 
or  rigidity  of  the  extremities,  with  a  decided  restriction  in  motion. 
There  may  be  rigidity  of  the  neck  muscles.  The  children  are  often 
"head-borers." 

One  extremity  may  show  much  more  involvement  than  the  other. 
Spasticity  and  lead-pipe  rigidity  characterize  the  condition  of  the 
muscles.  The  reflexes  are  usually  exaggerated.  Owing  to  the  per- 
sistent spasticity,  the  patient  may  be  unable  to  walk  or  use  the  hands. 
If  walking  is  accomplished,  it  is  learned  much  later  than  is  normal. 
Often  walking  is  interfered  with  because  of  spasm  of  the  adductors, 
which  produces  a  cross-legged  attitude.  In  those  cases  in  which  walk- 
ing is  finally  accomplished,  the  patient  is  very  awkward  and  falls  fre- 
quently. In  a  State  institution  for  defectives  which  I  recently  visited, 
70  out  of  300  inmates,  ranging  from  eight  years  to  over  forty,  had  never 
walked. 

The  physical  development  is  always  of  an  inferior  order  in  cases 
even  moderately  severe.  The  ability  to  hold  the  head  erect  is  ac- 
complished very  late.  I  have  repeatedly  had  patients  who  could  not 
support  the  head  at  the  fourth  or  fifth  year.  Deafness  and  blindness 
are  not  at  all  unusual.  Nystagmus  and  strabismus  are  frequently 
seen.  Speech  is  apt  to  be  acquired  late  and  may  be  very  defective. 
The  ability  to  swallow  solid  food  is  often  very  much  delayed.  Even 
the  swallowing  of  fluid  can  be  accomplished  only  in  a  certain  position. 
A  child  of  whom  I  had  charge  for  several  years  could  swallow  fluids 
only  when  resting  on  his  back.     The  impairment  continued  during  the 


CEREBRAL    PALSIES  515 

six  years  of  life  of  the  child.  The  physical  impairment  varies  widely 
in  degree  from  what  appears  as  simple  awkwardness  to  complete  inability 
to  perform  a  single  volitional  act.  The  legs  usually  show  much  greater 
involvement  than  the  arms.  A  child  who  has  little  or  no  use  of  the  legs 
may  be  able  to  use  the  arms  to  good  effect. 

Fortunately,  many  of  these  unfortunates  die  during  the  earlier 
years.  Their  resistance  to  infection  is  of  a  low  order.  Convulsions  may 
occur,  but  have  not  been  of  frequent  occurrence  in  my  own  cases. 

Mentality. — The  mental  capacity  is  also  of  wide  variation.  I  have 
under  my  care  at  the  time  of  writing  four  patients  with  normal  men- 
tality. Two,  through  gymnastic  exercises  and  training,  are  able  to 
perform  all  volitional  acts  and  are  looked  upon  as  normal  children. 
There  is  still  a  slight  impairment  in  gait,  and  they  are  known  among 
their  fellows  as  "  clumsy"  boys.  The  other  two,  girls,  possess  unusually 
bright  minds,  but  are  pronounced  diplegics.  One  is  fourteen  years 
of  age  and  has  never  walked  without  support,  the  other  is  six  years 
of  age.  She  is  now  walking  alone  but  with  much  difficulty.  The 
gait  is  still  decidedly  spastic.  She  has  had  daily  treatment  since 
two  years  of  age.  The  latter  will  probably  walk  in  a  year  or  two. 
On  the  other  hand  I  see  several  patients  every  year  whose  mentality 
is  of  a  very  low  order. 

Between  these  two  extremes  there  are  all  degrees  of  mental  impair- 
ment. Not  infrequently  these  defective  children  possess  decided 
brilliancy  along  a  certain  line,  while  the  mind  is  a  complete  blank 
in  other  respects.  Defectives  often  learn  to  accomplish  purely  mechan- 
ical acts  very  well  indeed.  They  may  become  intense  specialists. 
A  defective  boy  has  developed  into  an  expert  carver  of  wood.  I  have 
known  two  very  clever  musicians  who  were  defective  in  every  other 
respect. 

Epilepsy. — Authors  claim  that  epilepsy  is  present  in  a  considerable 
proportion  of  defectives.  Such  has  not  been  my  experience.  In  fact, 
in  a  large  experience  with  children  of  this  type  epilepsy  has  been  very 
exceptional. 

The  Acquired  Form 

Hemiplegia  may  be  said  to  characterize  the  acquired  cases,  and  while 
diplegia  and  paraplegia  may  occur,  this  is  the  exception. 

Etiology. — My  cases  have  all  been  the  result  of  infection,  stress, 
or  direct  trauma.  A  comparatively  trifling  injury  is  sometimes  suffi- 
cient to  produce  a  hemorrhage. 

Illustrative  Cases. — A  boy  twelve  years  of  age,  a  pronounced  hemiplegic  with 
normal  mentality,  owes  his  present  condition  to  a  fall  from  his  baby-carriage  to  the 
ground  when  nine  months  of  age.  The  fall  was  followed  by  repeated  convulsions 
and  hemiplegia.  He  came  under  my  care  a  few  days  after  the  fall.  The  clot  was 
located,  the  skull  trephined,  the  blood-clot  removed,  and  the  bleeding  vessel 
ligated.  The  boy  today  walks  well  with  a  brace;  the  arm  will  probably  never 
be  of  much  service. 

Another  child,  fourteen  months  of  age,  was  perfectly  normal  previous  to  an 
acute  attack  of  indigestion  with  high  fever  and  convulsions.  The  seizures  were 
repeated  several  times  during  the  day.     After  the  third  convulsion  it  was  noticed 


516  THE    PRACTICE    OF    PEDIATRICS 

that  there  was  complete  paralysis  of  the  left  side  of  the  face  and  of  the  right  arm 
and  leg.  The  child  died  thirteen  months  afterward.  His  mentality  was  never 
clear. 

A  mother  and  her  seven-months'-old  babe  went  in  bathing  at  the  seashore, 
the  babe  in  the  mother's  arms.  A  ground  swell  engulfed  them.  When  the  child 
was  resuscitated,  it  was  found  that  there  was  complete  hemiplegia. 

My  most  recent  case  occurred  during  pertussis.  Hemiplegia  developed  after 
a  severe  paroxysm.  The  child  lost  consciousness,  which  was  not  regained;  and 
death  followed  in  seventy  hours  as  a  result  of  cerebral  hemorrhage. 

A  child  eleven  months  of  age  fell  to  the  floor  from  his  crib  striking  on  the  head. 
Hemiplegia  developed  at  once,  followed  by  death  in  a  few  hours.  Autopsy  showed 
extensive  cerebral  hemorrhage. 

Hemiplegia  may  be  the  result  of  congenital  syphilis.  I  have  seen 
such  cases.  The  Wasserman  test  should  always  be  taken  in  every 
child  in  whom  hemiplegia  develops.  In  hemiplegia  with  congenital 
syphilis  there  is  usually  no  prodromal  symptom.  The  paralysis  is 
noticed  when  the  child  wakes  in  the  moT-ning  or  develops  spontane- 
ously during  the  day. 

Any  of  the  diseases  of  bacterial  origin  may  cause  cerebral  palsy  of 
the  hemiplegic  type.  Infection  as  a  cause,  however,  is  very  infrequent. 
(This  opinion  is  based  entirely  on  my  own  experience.)  More  cases 
probably  result  from  cerebrospinal  meningitis  than  from  any  other 
form  of  infection.  The  lesions  in  the  cases  reported  as  occurring  with 
various  infectious  diseases  and  gastro-enteric  disturbances  are  prob- 
ably the  result  of  the  convulsions  which  may  have  ushered  in  the 
illness. 

A  convulsion  is  never  without  danger  in  a  child. 

Age. — It  is  unusual  for  a  case  to  develop  after  the  seventh  year. 
The  majority  of  the  cases  occur  before  the  fourth  year. 

Symptoms. — The  first  symptom  is  usually  that  of  paralysis  follow- 
ing a  convulsion  or  trauma.  In  some  cases  there  is  paralysis  (hemi- 
plegia) only;  in  others,  profound  mental  disturbance.  The  duration 
of  the  paralysis  depends  upon  the  nature  and  extent  of  the  injury. 
The  paralysis,  which  is  spastic  in  character,  may  completely  disappear, 
or  permanent  disability  with  contractures  may  remain.  Usually  there 
is  some  impairment  of  power.  The  arm  functions  may  be  com- 
pletely restored.  The  leg  improves  less  rapidly,  and  is  more  apt  to 
show  permanent  disability.  (This  is  the  reverse  of  the  experience  of 
most  authors.)  Not  infrequently  the  patient  develops  one  of  the 
various  forms  of  club-foot,  which  means  that  certain  muscle  groups 
have  been  particularly  involved. 

The  facial  muscles  are  involved  in  a  small  proportion  of  the  cases — 
perhaps  15  per  cent.  Complete  restoration  to  the  normal  is  the  rule. 
The  patellar  reflex  is  usually  exaggerated  on  both  sides,  but  most 
markedly  in  the  leg  of  the  affected  side.  The  gait  may  be  interfered 
with,  or  the  function  of  the  limb  may  be  entirely  lost.  In  other  cases 
in  which  the  focal  lesion  is  less  pronounced,  walking  may  be  accom- 
plished after  orthopedic  attention. 

Electric  Reaction. — The  reaction  of  degeneration  is  usually  present. 

Sensation  is  not  permanently  disturbed.     Early  in  some  cases  there 


CEREBRAL    PALSIES  517 

appears  to  be  some  impairment;  this,  owing  to  the  mental  state  of  the 
patient,  may  be  difficult  to  determine  accurately. 

Disturbance  of  Speech. — Aphasia  is  present  when  there  is  a  left 
third  frontal  lobe  involvement.  Impairment  of  speech  may  also  occur 
when  the  right  hemisphere  is  affected,  although  to  a  lesser  degree. 
When  the  speech  center  in  the  left  hemisphere  is  involved,  the  right 
may  take  on  the  function. 

Incoordinate  Movements. — Incoordination  of  the  paralyzed  parts, 
particularly  of  the  arm,  has  been  repeatedly  observed.  These  non- 
volitional  movements  have  been  erroneously  termed  "choreic." 

Illustrative  Case. — A  patient  two  years  of  age  had,  at  the  age  of  one  year, 
repeated  and  prolonged  convulsions  covering  a  period  of  three  days.  Pronounced 
hemiplegia  resulted,  with  mental  impairment.  After  one  year  the  hemiplegia 
entirely  disappeared,  but  phenomena  of  muscle  gymnastics  remain  that  are 
difficult  to  describe.  The  child  rocks  and  sways  the  body.  The  muscles  of  the 
right  side  of  the  face  undergo  frequent  rapid  contractions  and  relaxations.  Volun- 
tary muscular  acts  are  readily  accomplished.  Athetosis  is  present  in  a  marked 
degree.  There  are  rhythmic  motions  of  the  flexors  and  extensors  of  the  fingers,  and 
flexors  and  extensors  of  the  forearm.     The  child's  mentality  is  still  much  impaired. 

Athetosis  is  of  more  usual  occurrence  in  cases  in  which  the  lesion 
has  apparently  been  severe. 

Epilepsy  may  be  expected  in  any  case  of  hemiplegia.  Gowers 
states  that  it  occurred  in  over  60  per  cent,  of  his  cases.  Sachs  reported 
epilepsy  in  50  per  cent.  Epilepsy  may  not  occur  until  several  years 
have  elapsed.  Thus,  in  a  case  of  my  own,  the  child  had  the  injury 
and  hemiplegia  when  nine  months  of  age,  and  did  not  develop  epilepsy 
until  the  tenth  year. 

Epilepsy,  when  it  develops,  is  usually  of  the  Jacksonian  type,  and 
is  often  very  mild  in  character. 

Mental  Impairment. — While  mental  impairment  may  be  said  to  be 
the  rule,  it  by  no  means  follows  that  a  child  with  hemiplegia  may 
not  be  perfectly  normal  mentally.  It  would  naturally  be  supposed 
that  involvement  early  in  life  would  be  particularly  likely  to  affect  the 
mentality,  and  such  is  the  case.  Nevertheless,  I  have  seen  patients 
with  conditions  of  this  nature  make  complete  recovery  and  become 
mentally  competent  individuals.  The  intelligence  may  be  normal,  or 
there  may  be  complete  idiocy,  or  any  degree  of  impairment  between 
these  extremes. 

Diagnosis. — The  diagnosis  is  not  difficult.  In  the  prenatal  and 
birth  cases  there  are  early  diplegia  and  paraplegia,  with  unmistakable 
evidence  of  mental  impairment.  The  child  does  not  smile  or  hold  up 
the  head  or  attempt  to  play  with  toys  at  the  usual  age,  and  is  slow  to 
recognize  people  or  surroundings.  There  may  be  difficulty  in  swallow- 
ing and  inability  to  perform  volitional  acts.  All  these  patients  have  a 
characteristic  vacant  expression —  a  meaningless  stare. 

In  the  acquired  cases  the  paralysis  is  unilateral,  with  exaggerated 
reflexes  on  the  involved  side. 

Further,  there  is  usually  the  history  of  trauma  and  sudden  onset. 

Treatment. — The  medical  treatment  of  the  paralysis  consists  in 


518  THE    PRACTICE    OE    PEDIATRICS 

maintaining  a  high  degree  of  nutrition.  The  management,  in  general, 
in  the  different  types  of  cases,  varies,  depending  upon  the  intelhgence 
of  the  patient,  the  location  and  extent  of  the  paralysis,  and  the  resulting 
deformity.  Braces  are  necessary  in  many  instances  to  prevent  con- 
tractures and  deformities,  as  well  as  to  aid  in  correcting  those  already 
present.  In  some  of  my  cases  of  normal  or  fair  mentality,  marked  im- 
provement has  followed  daily  systematic  manipulations  and  exercises 
(p.  830)  under  the  management  of  an  expert  in  this  line  of  work. 

A  description  of  operative  measures  and  a  discussion  of  the  cases  in 
which  they  are  applicable  may  be  found  in  all  works  on  orthopedics. 
Systematic  exercise,  massage,  and  training  in  the  use  of  the  limbs 
constitute  the  latter  management  of  all  operative  cases,  in  order  that 
the  patients  may  derive  full  benefit  from  the  operation. 

CHOREA  (ST.  VITUS'  DANCE) 

Chorea,  in  the  form  originally  described  by  Paracelsus,  is  extinct. 
In  the  Middle  Ages,  however,  a  form  of  dancing  mania  was  widely  epi- 
demic throughout  Europe,  and  sketches  will  testify  to  enormous  four- 
teenth century  pilgrimages  to  the  shrine  of  St.  Vitus.  The  term  chorea 
ordinarily  applies  to  the  condition  described  by  Sydenham,  in  1686; 
and  the  names  chorea  minor,  chorea  vulgaris,  and  chorea  anglorum  are 
synonymous. 

Under  the  general  title,  furthermore,  are  grouped  such  cases  as 
those  described  by  Huntington  in  1872  as  hereditary  in  type,  and  a 
large  heterogenous  collection  designated  by  such  self-explanatory  terms 
as  chronic  progressive  chorea,  chronic  adult  chorea,  congenital  chorea, 
senile  chorea,  chorea  gravidarum,  posthemiplegic  chorea,  choreic  insanity, 
and  electric  chorea  or  Dubinins  disease  (which  is  marked  by  the  sudden 
character  of  the  spasms).     Chorea  major  is  a  variety  of  hysteria. 

Incoordination  characterizes  chorea  in  children.  The  child's 
control  over  the  muscle  movement  is  partially  or  entirely  lost.  In 
addition,  there  are  involuntary  muscle  movements  and  twitchings,  and 
there  is  loss  of  muscle  power. 

Etiology. — The  disease  occurs  more  frequently  in  girls  than  in  boys 
The  proportion  in  my  own  cases  is  two  to  one. 

The  susceptible  age  is  from  the  sixth  to  the  tenth  year.  The  age 
range  in  my  own  cases  has  been  from  four  to  sixteen  years.  These  ob- 
servations are  in  accord  with  those  of  other  writers. 

Fright  as  a  factor  in  causing  chorea  has  been  greatly  overestimated. 
In  a  susceptible  child  the  occurrence  of  stress  of  any  nature  may  in- 
duce an  attack.  Regardless  of  the  nervous  shock,  there  is  no  chorea 
without  the  underlying  constitutional  vice.  Overwork  at  school  is  to 
be  looked  upon  as  a  predisposing  cause,  as  also  is  anemia  or  any 
influence  affecting  the  well-being  of  the  child.  But  such  conditions 
are  operative  only  in  favorable  subjects. 

Basing  my  judgment  on  a  large  number  of  cases  both  in  private  and 
out-patient  work,  I  agree  with  the  accepted  opinion  of  most  writers 
that  rheumatism  takes  a  first  place  in  the  etiology  of  this  disease. 


CHOREA    (sT.    VITUS'  DANCE)  519 

Striimpell  several  years  ago  wrote  that  the  association  of  chorea  and 
rheumatism  is  so  close  that  it  is  impossible  to  separate  them.  Hirt, 
in  discussing  nervous  diseases,  expressed  the  view  that  there  is  a  com- 
mon toxic  etiologic  factor  which,  affecting  the  cortex,  produces  chorea, 
but  affecting  the  joints  gives  rise  to  acute  articular  rheumatism.  The 
association  of  rheumatism  and  chorea  is  certainly  most  intimate.  A 
trifle  over  50  per  cent,  of  my  cases  either  gave  a  history  of  rheumatic 
manifestations,  or  showed  evidence  of  rheumatism,  when  first  seen,  or 
developed  the  signs  later. 

If  to  the  above  are  added  the  cases  of  chorea  in  which  there  is  a 
family  history  of  some  form  of  rheumatism,  the  percentage  is  increased 
to  over  80  per  cent.  The  association  so  generally  observed  clinically 
is  further  borne  out  by  the  results  of  treatment. 

Pathology, — Much  has  been  written  concerning  the  pathology,  and 
widely  diverse  opinions  are  held.  The  fact  that  the  child  makes  a 
complete  recovery  in  a  few  weeks,  and  that  no  permanent  lesion  is 
demonstrable  after  several  acute  attacks,  proves  that  there  is  no  grave 
lesion.  A  systemic  toxemia  affecting  the  centers  in  the  cortex  is  un- 
questionably present. 

Poynton  and  Paine  have  found  the  diplococcus  of  rheumatism  in 
films  made  from  the  pia  mater  in  a  fatal  case  of  chorea.  The  cocci 
were  seen  in  the  vicinity  of  a  blood-vessel.  Poynton*  gives  a  cut 
showing  this  condition,  but  no  further  details.  Morse  and  Floyd 
found  cocci  in  the  blood  in  four  out  of  31  chorea  cases  studied  but 
their  work  proved  nothing  definite. 

The  spinal  fluid  in  chorea  is  clear.  In  about  30  per  cent,  of  cases 
Morse  and  Floyd  found  a  very  slight  increase  in  the  number  of  cells, 
all  of  which  were  mononuclear  in  type.  No  micro-organisms  are 
present. 

Symptoms. — The  onset  of  symptoms  is  most  variable.  Usually  the 
child  will  show  apparent  awkwardness  in  using  one  of  the  hands,  or  will 
stumble  in  walking  or  will  exhibit  a  hesitancy  in  speech  which  is  un- 
usual. Such  symptoms  will  be  present  for  a  week  or  more  and  the 
child  will  usually  be  reproved  for  his  awkwardness  in  handling  his 
drinking  glass,  knife  or  fork.  The  condition  may  go  no  further  than 
this,  or,  as  is  usually  the  case,  the  nervous  manifestations  continue. 
The  arms,  hands,  and  fingers  may  twitch  and  show  short  clonic  con- 
tractions of  certain  muscles.  At  the  commencement  one  arm  is 
usually  involved  more  than  the  other.  This  tendency  to  lateral  in- 
volvement may  continue  throughout  the  attack.  The  order  of  in- 
volvement is  usually  the  right  arm,  left  arm,  right  leg,  and  left  leg. 
The  limb  involved  is  much  weaker  than  its  fellow.  This,  in  the  ex- 
aminations of  the  upper  extremities,  may  be  readily  appreciated  by 
asking  the  patient  to  squeeze  the  examiner's  hand,  the  patient  using 
first  one  hand  and  then  the  other. 

The  muscles  of  the  face  or  of  the  shoulders,  in  fact,  those  of  any  por- 
tion of  the  body,  may  be  prominently  involved,  but  this  is  unusual. 
*  "The  British  Journal  of  Children's  Diseases,"  1912,  vol.  ix,  p.  49. 


520  THE    PRACTICE    OF    PEDIATRICS 

In  association  witii  the  involuntary  muscular  contractions,  there  is 
lack  of  coordination,  a  further  development  of  the  awkwardness  seen 
early  in  the  attack.  The  movement  of  the  hand,  for  example,  is  slow 
or  absolutely  refuses  to  obey  the  will,  and  the  movement  is  only  ac- 
complished after  pronounced  effort  or  not  at  all.  Thus  when  a  choreic 
patient  is  told  to  place  the  tip  of  one  index-finger  on  the  tip  of  the  nose 
or  the  tip  of  each  index-finger  alternately  on  the  tip  of  the  nose  in  re- 
peated succession,  returning  the  arms  in  an  extended  position  to  his 
sides,  the  child  experiences  much  confusion,  and  the  fingers  rarely  reach 
the  tip  of  the  nose.  Another  test  is  to  extend  the  arms  in  an  outward 
direction  and  then  bring  the  tips  of  the  index-fingers  together  quickly. 
The  choreic  patient  will  experience  much  difficulty  in  its  accomplish- 
ment. I  have  had  eight  patients  under  ten  years  of  age  who  were  con- 
fined to  their  beds  and  who  could  perform  no  voluntary  act.  Self- 
feeding  was  out  of  the  question ;  and  walking,  an  impossibility. 

Muscle  instability  may  be  further  demonstrated  by  the  inability 
of  the  patient  to  maintain  muscle  tension.  Thus,  wrinkling  the  brows 
or  holding  the  eyes  tightly  shut  can  be  continued  but  a  few  seconds. 
When  the  child  is  asked  to  protrude  the  tongue  and  keep  it  protruded, 
the  organ  may  undergo  various  contractions  until  it  is  under  control, 
and  even  when  at  rest  will  show  fine  fibrillary  twitchings.  The  facial 
muscles  offer  a  large  field  for  muscle  gymnastics  with  grotesque  effects. 
All  or  any  of  the  voluntary  muscles  may  be  involved.  There  is  inco- 
ordination, and  lack  of  power  and  muscle  control. 

Diagnosis. — The  diagnosis  is  made  on  the  presence  of  muscle  con- 
tractions beyond  the  control  of  the  will,  resulting  in  awkwardness, 
grimaces,  and  inability  to  effect  voluntary  effort.  Chorea  is  to  be 
differentiated  from  habit  spasm — so-called  "habit  chorea" — by  the 
fact  that,  in  the  latter,  while  there  are  contractions  of  various  sets  of 
muscles  in  the  body,  such  contractions  may  be  controlled  by  mental 
concentration,  whereas  in  true  chorea  the  attempt  at  control  exagger- 
ates the  incoordination. 

Prognosis. — The  prognosis  is  good.  I  have  seen  a  large  number  of 
cases  and  have  never  known  one  that  did  not  recover  if  the  patient  was 
free  from  cardiac  involvement.  I  have  seen  fatal  cases  of  pancarditis 
(endocarditis,  myocarditis,  and  pericarditis)  in  which  chorea  was  one  of 
the  symptoms  of  the  rheumatic  infection,  but  in  every  case  it  was  the 
heart  involvement  that  killed  the  patient. 

Recurrence. — As  with  other  rheumatic  manifestations  in  children, 
there  is  with  chorea  a  marked  tendency  toward  a  return.  In  its  causa- 
tion there  is,  moreover,  a  seasonal  element.  The  majority  of  the  cases 
occur  in  the  spring  months  of  April  and  May.  It  has  not  been  my  ob- 
servation that  the  fall  of  the  year  is  a  predisposing  factor.  Repeatedly 
in  out-patient  work  where  continuous  supervision  is  impossible  I  have 
seen  these  choreic  children  return  year  after  year  for  treatment.  We 
get  acquainted  with  the  children  and  look  for  their  return. 

Duration. — The  duration  of  these  cases  depends  upon  the  nervous 
organization  of  the  child,  the  severity  of  the  attack,  and  the  cooperation 


CHOREA  (sT.  Vitus'  dance)  521 

to  be  gained  from  the  patient's  family.  I  have  had  fairly  severe  cases 
recover  in  six  weeks,  and  others  that  required  six  months  of  treatment. 

Treatment. — Rest  Treatment. — The  management  of  chorea  depends 
entirely  upon  the  degree  of  severity  of  the  attack.  It  may  be  neces- 
sary in  extreme  cases  to  keep  the  child  in  bed  from  three  to  four  weeks. 
In  other  cases,  in  which  the  attack  is  milder  in  character,  the  enforced 
rest  may  do  harm.  Formerly  I  treated  more  cases  on  the  plan  of  ex- 
treme rest  than  I  do  at  present.  When  the  involuntary  movements 
are  so  marked  as  to  interfere  with  locomotion  and  prevent  the  child's 
feeding  himself,  rest  in  bed  for  a  week  or  two  is  strongly  advised.  In 
my  observation  it  is  mental  repose  that  the  patients  particularly  re- 
quire, and  if  this  can  best  be  obtained  in  bed,  then  the  bed  is  the  best 
place  for  the  patient.  If  an  absence  of  mental  excitement  and  stimu- 
lation can  be  secured,  with  a  reasonable  amount  of  outdoor  life  and 
exercise,  so  much  the  better.  An  important  fact  to  be  remembered  in 
the  management  of  choreic  children  is  that  they  must  not  be  allowed 
to  become  fatigued  either  physically  or  mentally. 

For  the  patient  who  has  been  confined  to  bed  for  several  days 
or  weeks,  a  gradual  return  to  the  usual  habits  is  best.  The  child  should 
be  taken  up  for  one-half  hour  the  first  day,  increasing  the  time  out  of 
bed  one-half  hour  daily,  until  he  returns  to  his  usual  habits  of  life. 

School  and  Entertainment. — Specific  instructions  as  to  the  amount 
of  physical  and  mental  rest  required  cannot  be  given  so  as  to  apply 
generally  in  the  management  of  chorea.  School  and  entertainments 
for  the  choreic  patient  are,  however,  out  of  the  question,  no  matter 
how  mild  the  case.  In  the  great  majority  of  cases  play  with  other 
children  must  be  prohibited.  Books  and  play  of  an  exciting  nature 
are  to  be  particularly  avoided.  The  physician  shouM  especially  re- 
member that  there  must  be  no  bodily  fatigue  and  no  mental  stimula- 
tion of  any  nature  whatever.  How  best  to  bring  this  about  will  depend 
upon  the  child  and  his  environment. 

In  two  instances  I  have  been  obliged  to  remove  the  patient  from  his 
home  to  a  place  among  other  relatives.  The  influence  of  the  mother 
was  such  as  hopelessly  to  prevent  the  child's  recovery.  In  a  recent 
severe  case  of  a  boy  of  twelve  years,  a  college  student  was  selected  to 
turn  the  patient's  attention  to  boyish  things,  games,  target  practice, 
horseback  riding,  etc.  The  boy  was  kept  in  bed  until  9  a.  m.,  rested 
two  hours  after  the  midday  meal,  and  retired  at  7  p.  m.  He  was  prac- 
tically well  in  four  weeks. 

Antirheumatic  Treatment. — By  treating  every  case  of  chorea  as 
though  the  disease  were  rheumatism,  my  results  have  been  strikingly 
good.  Not  only  is  the  child  given  the  salicylates,  but  he  is  put  on  an 
antirheumatic  diet.  The  tonsils  should  receive  careful  attention,  and 
in  repeated  attacks  enucleation  should  be  practised. 

Drugs. — The  salicylate  of  soda  (true)  may  be  given  in  smaller  doses 
than  are  used  in  acute  articular  rheumatism — about  5  grains  three 
times  daily,  with  an  equal  amount  of  the  bicarbonate  of  soda,  being 
suitable  for  a  child  from  six  to  ten  years  of  age.     The  soda  should  be 


522  THE    PRACTICE    OF    PEDIATRICS 

given  between  meals.  To  children  of  this  age  the  salicylate  may  be 
given  either  in  capsule  or  in  solution.  In  the  treatment  of  young  chil- 
dren, the  drugs  in  solution  are  more  easily  administered.  During  the 
past  3^ear  I  have  given  aspirin  to  a  few  patients  in  whom  the  digestive 
functions  were  weak  or  who  could  not  take  the  salicylate  of  soda.  In 
using  salicylate  of  soda  or  aspirin  for  a  considerable  time  it  is  well  to 
remember  that  they  may  interfere  with  the  appetite  and  digestion,  no 
matter  how  great  the  care  exercised  in  their  use.  For  this  reason  it 
is  my  custom  to  give  them  intermittently — five  days  of  medication 
being  followed  by  five  days  without  medicine. 

In  spite  of  the  value  of  the  antirheumatic  treatment,  this  alone  will 
not  answer,  as  I  have  proved  to  my  satisfaction  in  not  a  few  cases. 
The  administration  of  the  arsenic  and  the  salicylate  and  the  dietetic 
regime  are  begun  at  the  same  time.  The  salicylate  of  soda  is  given  at 
once  at  the  commencement  of  the  treatment  in  as  full  doses  as  we  ex- 
pect to  give.  Arsenic  is  commenced  in  a  small  dose,  which  is  gradually 
increased  in  order  to  establish  a  tolerance  of  the  drug.  Fowler's  solu- 
tion of  arsenic  is  usually  employed.  In  order  that  no  error  be  made 
in  its  administration,  a  table  similar  to  the  following  is  given  to  the 
mother  or  attendant.  For  a  child  six  years  of  age,  on  the  first  day, 
two  drops  should  be  given  after  each  meal,  as  indicated  below.  There- 
after, the  dosage  is  increased  by  one  drop  every  twenty-four  hours, 
according  to  the  following  schedule: 

DOSAGE  OF  FOWLER'S  SOLUTION  FOR  A  CHILD  SIX  YEARS  OLD 

1st  day — morning,  2  drops.     Noon,  2  drops.     Night,  2  drops. 


2d      " 

(( 

2 

" 

ti 

2 

ti 

u 

3 

3d      " 

(( 

2 

(( 

11 

3 

a 

<( 

3 

4th    " 

f( 

3 

ti 

u 

3 

ii 

n 

3 

This  rate  of  daily  increase  is  continued  up  to  the  third  week,  after 
which  time  the  dosage  should  range  from  5  to  10  drops  three  times  a 
day.  For  a  child  of  eight  to  ten  years  of  age  the  amount  may  be  in- 
creased to  12  or  15  drops  three  times  a  day.  I  have  found  that  by 
putting  the  patient  on  the  antirheumatic  treatment  much  less  arsenic 
is  required,  and  that  the  patient  usually  makes  an  earlier  recovery.  I 
have  never  been  obliged  to  resort  to  the  large  dosage  of  25  to  30  drops 
of  Fowler's  solution  three  times  a  day,  as  suggested  by  Seguin.  It  is 
exceedingly  rare  that  more  than  10  drops  three  times  daily  will  be 
required  in  order  to  procure  satisfactory  results.  I  have  never  found 
it  necessary  to  give  more  than  12-drop  doses  to  girls  of  thirteen  to  six- 
teen years  old.  A  very  recent  aggravated  case  in  a  girl  fifteen  years 
of  age  terminated  in  complete  recovery  in  three  weeks  under  the  anti- 
rheumatic diet,  the  use  of  aspirin,  10  grains  three  times  daily  after 
meals,  and  Fowler's  solution  up  to  12  drops  after  each  meal. 

Children  vary  greatly  as  to  their  tolerance  of  arsenic.  A  boy  seven 
years  old  could  not  take  more  than  four  drops  of  Fowler's  solution 
three  times  a  day. 

In  giving  arsenic,  mothers  should  therefore  be  advised  that  in  the 


CHOREA    (sT.    VITUS'    DANCE)  523 

event  of  abdominal  pain,  diarrhea,  coated  tongue,  foul  breath,  vomit- 
ing, or  puffiness  under  the  eyes,  the  drug  is  to  be  discontinued  for  at 
least  two  days.  The  minimum  dose  may  then  be  resumed  with  the 
isame  gradual  increase. 

With  the  improvement  of  the  case  the  diet  should  be  continued. 
The  medication  may  gradually  be  reduced  after  all  the  symptoms  have 
disappeared.  It  should  be  continued,  however,  in  from  one-third  to 
one-half  the  quantity  for  three  weeks  after  the  disappearance  of  all 
nervous  symptoms. 

Supplementary  Treatment. — It  should  be  remembered  that  children 
who  have  once  had  chorea  are  very  susceptible  to  recurrent  attacks. 
This  is  also  the  case  with  children  who  have  had  rheumatism.  After 
one  attack  of  chorea  the  danger  of  a  recurrence  should  be  explained 
to  the  mother,  who  should  be  asked  to  bring  the  child  for  examination 
at  the  first  suggestion  of  involuntary  muscular  twitching.  In  addition 
to  this,  children  who  have  had  chorea,  as  well  as  those  who  have  had 
rheumatism,  should  be  allowed  meat  but  once  every  second  day,  and 
in  no  case  should  an  excessive  use  of  sugar  be  permitted.  Candy  is 
usually  to  be  forbidden.  Believing  that  these  cases  are  rheumatic  in 
origin,  when  the  attack  is  over  I  order  that  the  child  shall  receive  10 
grains  of  bicarbonate  of  soda  three  times  daily  for  five  days  out  of 
overy  fifteen.  In  this  way,  under  a  reasonably  quiet  home  life,  with 
no  school  contests  for  prizes,  etc.,  a  recurrence  will  almost  invariably 
be  prevented. 

Goodman  reports  30  cases  of  chorea  treated  by  the  auto-serum 
method,  which  is  carried  out  as  follows: 

After  having  excluded  tuberculosis  and  syphilis,  we  permit  the 
<;hild  to  lie  in  bed  for  three  or  four  days  or  longer,  without  any  medica- 
tion. We  then  withdraw  from  a  vein  45  or  50  c.c.  of  blood,  and  rapidly 
.  centrifugalize  it.  The  serum  is  then  pipetted  off  and  kept  on  ice. 
A  lumbar  puncture  is  performed  in  the  usual  manner.  The  fluid  is 
very  slowly  withdrawn,  and  about  20  c.c.  of  the  fluid  is  collected. 
The  .serum  is  then  heated  to  body  temperature,  and  very  slowly  in- 
jected into  the  spinal  canal.  Such  an  injection  should  take  from  ten 
to  fifteen  minutes,  and  usually  15  to  18  c.c.  of  the  serum  is  used.  The 
patient  should  retain  the  recumbent  position  for  at  least  one  hour 
after  the  injection.  From  one  to  four  injections  were  given — the 
interval  is  not  stated. 

Goodman  summarizes  as  follows:  Of  the  30  cases,  18  were  female 
and  12  were  male.  The  youngest  case  injected  was  four  years  of  age, 
the  oldest,  twenty-eight. 

Of  the  30  cases  injected,  18  were  under  ten  years  of  age,  10  were 
from  ten  to  fifteen  years  of  age,  1  from  fifteen  to  twenty  years  of  age, 
and  1  from  twenty  to  thirty  years  of  age. 

Of  the  30  cases  treated,  14  received  one  injection,  8  received  two 
injections,  5  received  three  injections,  and  3  received  four  injections. 

Of  those  receiving  one  injection,  12  were  cured  and  2  markedly 
improved. 


524  THE    PRACTICE    OF    PEDIATRICS 

Of  those  receiving  two  injections,  5  were  cured  and  3  markedly 
improved. 

Of  those  receiving  three  injections,  2  were  cured  and  1  markedly- 
improved,  1  slightly  improved,  and  1  unimproved. 

Of  those  receiving  four  injections,  1  was  cured,  1  markedly  im- 
proved, and  1  unimproved. 

To  explain  our  interpretation  of  the  results,  cured  means  absolute 
cessation  of  all  twitchings  within  a  week.  Markedly  improved,  a 
cessatioii  of  all  twitchings  within  two  weeks.  Slightly  improved, 
when  the  twitching  disappears  at  the  end  of  the  third  week  and 
unimpaired  if  the  twitchings  are  still  present  during  the  fourth  week. 
Two  of  the  cases  reported  are  relapses.  One  occurred  after  9  months 
and  the  other  after  11  months. 

HABIT  SPASM  (TIG)* 

By  habit  spasm  is  understood  a  semi-incoordinate  movement  of 
some  portion  of  the  body.  The  term  "semi-incoordinate"  is  used  ad- 
visedly, because  the  spasm  may  be  controlled  when  the  child's  atten- 
tion is  directed  to  it,  this  being  one  of  the  distinguishing  features  which 
differentiates  it  from  chorea,  in  which  efforts  at  control  make  the  spasm 
worse.  The  muscles  involved  in  the  spasm  are  usually  those  of  the 
head,  face,  or  arm.  The  nose  may  be  drawn  up,  the  chin  down,  or  the 
head  to  either  side.  The  muscular  spasm  is  worse  when  the  patient 
is  tired,  and  occurs  more  frequently  under  excitement.  While  these 
children  cannot  be  said  to  have  chorea,  there  is  nevertheless  a  close 
association  between  habit  spasm  and  true  chorea.  Habit  spasm  is 
most  frequently  seen  in  those  of  rheumatic  inheritance  who  have  had 
previous  attacks  of  chorea  or  rheumatism,  or  the  respiratory  mani- 
festations so  frequently  seen  in  children  of  the  rheumatic  type. 

Several  of  my  patients  developed  habit  spasm  from  association 
with  children  who  had  some  special  grimace  or  habit  of  muscle  con- 
traction of  their  own. 

The  cases  are  readily  curable  when  taken  early.  In  neglected  chil^ 
dren  the  spasm  may  become  fixed  and  continue  during  the  life  of  the 
individual.  Instances  of  this  sort  are  often  seen  in  adults.  Bad  sub- 
jects will  transfer  the  spasm  from  one  set  of  muscles  to  another. 

Illustrative  Case. — A  boy,  twelve  years  old,  came  to  me  because  of  a  peculiar 
explosive  sound  similar  to  that  made  by  eructations  of  gas.  The  sound  was  pro- 
duced through  some  process  of  laryngeal  gymnastics  and  was  almost  continuous 
when  awake. 

Treatment. — The  management  is  dietetic,  hygienic,  and  medicinal. 

Diet. — I  allow  these  patients  a  small  portion  of  red  meat  once  a 
day.  Sugar  is  given  in  sufficient  amount  to  make  the  food  palatable. 
The  vegetable  and  legume  constituents  in  the  diet  are  made  prominent. 

*  Dr.  Edward  Wheeler  Scripture,  in  his  treatment  of  tics,  has  his  patients 
stand  in  front  of  a  mirror  and  imitate  the  tic,  thus  converting  it  from  an  involuntary 
to  a  volitional  one.  By  this  means  he  shows  surprising  results,  especially  when  the 
tic  is  of  recent  acquirement. 


STAMMERING  525 

The  patient  will  usually  be  found  to  be  poorly  nourished  and  often 
suffering  from  a  secondary  anemia,  so  that  a  diet  best  calculated  to 
improve  his  general  condition  should  be  insisted  upon.  This  should 
contain  milk,  eggs,  poultry,  fish,  red  meat  in  small  portion,  high-pro- 
teid  cereals,  and  the  legumes. 

Bath. — A  salt  bath  should  be  given  at  bedtime,  and  immediately 
after  the  bath  goose  oil,  unsalted  lard,  or  olive  oil  should  be  rubbed 
into  the  skin. 

School  Duties. — 'Temporary  absence  from  school,  or  a  lightening  of 
school  duties,  and  an  outdoor  life  are  essential  in  the  successful  man- 
agement of  a  case.  The  child  should  not  be  allowed  to  do  anything 
of  a  strenuous  nature.  Hard  play  and  any  amusement  of  an  exciting 
character  should  be  forbidden.  Fatigue  must  be  avoided.  Rest  after 
the  noon-day  meal  for  an  hour  or  two  is  strongly  recommended. 

Medication. — The  medicinal  treatment  suggested  for  chorea  is  also 
applicable  here.  If  there  is  anemia,  iron  may  be  given,  preferably  in 
the  form  of  the  extractum  ferri  pomatum,  3-^  grain  three  times  a  day. 
For  those  children  who  cannot  take  cream  or  butter,  cod-liver  oil  in 
teaspoonful  doses  is  a  valuable  addition  to  the  treatment.  The  iron 
may  be  alternated  with  the  cod-liver  oil,  each  being  given  for  five 
days.  If  there  is  a  rheumatic  history  or  inheritance,  aspirin  or  salicy- 
late of  soda — preferably  aspirin — is  to  be  given  in  capsule  with  the 
iron.     The  following  is  useful  for  a  child  five  years  of  age: 

I^     Liquoris  potassii  arsenitis gtt.  iij 

Ext.  ferri  pomati gr.  ss 

Aspirini gr.  iij 

M.  Sig. — One  dose;  to  be  given  in  capsule  after  each  meal. 

The  use  of  arsenic,  while  of  advantage,  does  not  appear  to  be  as 
valuable  here  as  in  chorea. 

Moral  Treatment. — Habit  spasm,  for  the  reason  that  it  is  practical^ 
under  the  control  of  the  will,  should  be  strictly  forbidden,  rewards 
being  given  and  punishments  imposed,  as  seem  to  answer  best. 

STAMMERING 

Stammering  is  an  affection  for  the  most  part  limited  to  self-con- 
scious and  precocious  children  with  indifferent  nervous  control.  The 
defect  is  seldom  of  importance  before  the  fifth  year  and  then  usually 
may  be  found  to  be  due  to  imitation  of  other  stammerers.  About  35 
per  cent,  of  the  patients  are  said  to  have  relatives  similarly  affected. 
Boys  are  more  frequent  victims  than  girls.  Fright  gives  rise  to  the 
condition  in  many  instances.  Of  the  concrete  causes  the  most  im- 
portant are  adenoid  and  tonsillar  hypertrophy,  high  palatal  arch,  im- 
perfect epiglottis,  and  short  frenum  linguae.  The  respiratory  muscles 
commonly  do  not  coordinate  properly  with  the  speech  muscles  and 
thus  the  subject  even  when  in  the  act  of  articulating  may  lack  the 
necessary  voice.  In  the  most  pronounced  cases  not  only  the  lips  and 
tongue,  but  also  the  face  and  limbs  participate  in  the  loss  of  control 
so  that  the  child's  self-reliance  becomes  greatly  weakened. 


526  THE    PRACTICE    OF   PEDIATRICS 

Treatment. — All  measures  that  conduce  to  stability  of  the  nervous 
system  are  of  value  in  the  cure  of  stammering.  Anatomical  abnor- 
malities should  be  corrected  and  breathing  exercises  should  be  insti- 
tuted to  encourage  better  poise  and  coordination.  Hollander  reports 
the  best  results  gained  from  suggestion  treatment  intended  to  increase 
the  patient's  self-confidence  and  emphasize  the  importance  of  his  ideas, 
rather  than  his  manner  of  utterance.  Syllabication  is  a  practice  of 
special  value. 

In  the  large  centers  there  are  clinics  for  the  treatment  of  speech 
defects  and  the  results  gained  by  speciahsts  in  this  department  amply 
justify  the  formation  of  more  such  classes  under  trained  supervision. 

THE  PROGRESSIVE  MUSCULAR  ATROPHIES 

The  progressive  muscular  atrophies  fall  easily  into  two  main  groups, 
called  the  amyotrophies  and  the  myopathies.  In  cases  of  the  first  class 
there  are  lesions  in  the  spinal  cord.  In  cases  of  the  second  group  such 
changes  are  not  found. 

Progressive  Spinal  Muscular  Atrophy  or  Progressive  Amyotrophy 

This  disease  has  received  many  designations,  including  the  follow- 
ing: Chronic  anterior  poliomyelitis,  wasting  palsy,  Charcot's  diseasey 
Duchenne- Aran's  disease,  and  amyotrophic  lateral  sclerosis. 

Some  justification  for  the  existence  of  so  many  terms  is  found  both 
in  the  variable  pathologic  conditions  and  also  in  the  length  of  the 
period  of  painstaking  research  which  has  made  possible  our  present 
knowledge  of  the  disease.  The  conditions  observed  are,  however, 
fundamentally  similar  and  admit  of  a  common  classification. 

Etiology. — Progressive  amyotrophy  is  uncommon  in  early  child- 
hood, although  Werdnig  and  Hoffmann  have  recognized  a  hereditary- 
form  occurring  in  the  very  young.  Older  children  and  young  adults 
are  more  frequently  affected,  and  in  such  instances  there  is  usually  na 
family  history  of  this  paralysis  and  the  disease  can  be  ascribed  only 
to  such  uncertain  causes  as  exposure,  overwork,  injury,  or  previous 
infectious  fevers,  including  poliomyelitis  of  the  acute  type.  An  excep- 
tion to  this  rule  occurs  in  the  case  of  progressive  muscular  atrophy  of 
the  Charcot-Marie  or  leg  type.  This  form  is  quite  definitely  a  family 
disease. 

Pathology. — The  essential  change  common  to  all  types  is  atrophy 
and  degeneration  of  the  anterior  cornua  of  the  spinal  cord.  This 
process  involves  the  cord  vertically  and  is  followed  by  degeneration  of 
the  peripheral  nerves  and  the  muscles  which  these  nerves  supply. 
Secondary  changes  in  the  cord  substance  consist  chiefly  of  sclerosis  and 
pigmentation  which  invade  the  pyramidal  tracts  and  also,  in  most 
cases,  the  anterolateral  ground-bundles.  Although  the  cervical  and 
upper  dorsal  regions  are  principally  affected,  the  disease  may  also  at- 
tack the  lumbar  region  or  the  motor  nerve-cells  of  the  medulla,  which 
supply  fibers  to  the  lips,  tongue,  pharynx,  and  larynx.  Muscular 
atrophy  of  the  leg  type  has  been  regarded  as  a  disease  of  neural  rather 


THE  PROGRESSIVE  MUSCULAR  ATROPHIES         527 

than  of  spinal  origin.  This  form,  however,  cannot  be  classed  with  the 
myopathies,  and  quite  probably  develops  from  primary  degeneration 
in  the  anterior  cornua. 

In  h  certain  proportion  of  spinal  muscular  atrophies  a  marked 
sclerosis  of  the  lateral  columns  supplements  the  usual  changes  secondary 
to  atrophy  of  the  cells  in  the  anterior  horns.  "The  degenerative  proc- 
ess attacks  first  the  terminal  fibers  and  collaterals  of  the  cortical  motor 
neurons.  It  seems  to  destroy  the  tips  of  the  nerve  processes,  so  to 
speak,  without  involving  the  nerve-cell  body  itself.  The  next  part  at- 
tacked is  the  anterior  cornual  cell"  (Dana).  Under  these  conditions 
the  progressive  amoytrophy  assumes  a  spastic  form  and  is  called  amyo- 
trophic lateral  sclerosis. 

Until  the  complex  pathology  which  has  just  been  briefly  traced  is 
further  elucidated,  the  following  neurologic  conditions  may  be  classi- 
fied under  the  general  heading,  "  progressive  spinal  muscular  atrophy : " 

1.  Progressive  amyotrophy  of  the  hand  type  (or  Duchenne-Aran  type). 

2.  Progressive  bulbar  paralysis. 

3.  Progressive  muscular  atrophy  of  the  leg  type  (peroneal  type  or  Char- 
cot-Marie-Tooth  type). 

4.  Progressive  spinal  muscular  atrophy  of  the  spastic  type  (or  amyo- 
trophic lateral  sclerosis). 

Symptomatology. — 1.  Progressive  amyotrophy  of  the  hand  type  typic- 
ally begins  as  a  wasting  of  the  muscles  of  one  thumb.  The  adductor 
pollicis,  deep  thenar,  hypothenar,  and  the  interossei  muscles  are  pro- 
gressively involved;  and  as  the  paralysis  extends,  it  may  affect  the 
flexors  and  extensors  of  the  forearm,  and  eventually  the  triceps  and 
deltoid  and  other  shoulder  muscles.  The  "claw-hand"  deformity  is 
common.  After  several  months  the  paralysis  may  become  bilateral, 
involving  the  trunk  and  rarely  the  leg  muscles,  or  it  may  even  develop 
into  a  bulbar  palsy.  The  paralysis  in  the  hand  type  of  atrophy  is 
usually  atonic  and  flaccid,  but  may  assume  a  spastic  character,  with 
exaggerated  reflexes,  thus  simulating  amyotrophic  lateral  sclerosis. 
The  varying  degrees  of  atony  and  spasticity  are  many.  In  most  cases 
fibrillary  contractions  occur.  Electric  responses  are  diminished  and 
partial  or  complete  reactions  of  degeneration  may  be  elicited.  Com- 
plete reactions  of  degeneration  belong,  as  a  rule,  to  cases  of  rapid 
course.  Occasionally  rheumatoid  pains  and  local  paresthesias  occur, 
but  sensory  disturbances  are  for  the  most  part  lacking. 

2.  Progressive  bulbar  paralysis  is  unusual  in  children.  Occasionally 
it  marks  the  termination  of  an  advancing  amyotrophic  lateral  sclerosis 
or  ophthalmoplegia.  Dysphonia  and  dysphagia  are  the  cardinal 
symptoms.  Localized  fibrillary  twitchings  may  occur.  Electric  irrit- 
ability is  gradually  diminished. 

3.  Progressive  muscular  atrophy  of  the  leg  type  attacks  first  the  pero- 
nei,  then  the  anterior  tibial  muscles  and  the  calf  muscles,  and,  at  a 
late  stage,  the  adductors  of  the  thigh  and  gluteal  muscles. 

In  cases  of  the  so-called  ascending  type  the  arms  and  trunk  may 
become  affected.     At  the  outset  the  paralysis  and  atrophy  are  uni- 


528 


THE    PRACTICE    OF    PEDIATRICS 


lateral.  Fibrillary  twitchings  and  diminished  electric  responses  are 
observed,  but  there  are  no  significant  sensory  symptoms. 

4.  Progressive  spinal  muscular  atrophy  of  the  spastic  type  combines 
the  symptoms  of  tonic  paralysis  with  those  of  progressive  wasting. 
The  affected  extremities  are  stiff  and  weak,  reflexes  are  exaggerated, 
and  in  certain  instances  the  lips,  tongue,  and  larynx  may  be  involved. 

Course  and  Prognosis. — In  all  these  conditions  the  course  of  the 
disease  is  very  chronic  and  extends  over  a  period  of  years.  The  pro- 
gressive amyotrophies  are  apparently  incurable,  though  remissions  in 
the  symptoms  are  frequent.  Atrophy  of  the  leg  type  is  said  to  offer 
the  best  prognosis. 

Diagnosis. — Cases  of  progressive  muscular  atrophy  in  children  are 
to  be  distinguished  from  those  of  primary  myopathy,  peripheral  neu- 


Fig.  72. — Pseudomuscular  hypertrophy.     (Early  case.) 

litis,  acute  poliomyelitis,  and  hereditary  ataxia.  The  individual  forms 
of  amyotrophy  should  also  be  distinguished.  Without  attempt  to 
enumerate  all  the  factors  valuable  in  these  differentiations  we  may 
group  together  the  following  points: 

In  the  amy  apathies:  Family  history  and  absence  of  fibrillary  tremor 
and  reaction  of  degeneration. 

In  neuritis:  Symmetric  distribution  of  paralysis,  possible  toxic  origin, 
frequent  existence  of  sensory  symptoms,  and  absence  of  family  history. 

In  epidemic  poliomyelitis :  History  of  acute  onset  and  rapid  course. 

In  hereditary  ataxia:  Characteristic  tottering  gait,  normal  electric 
reactions,  and  hereditary  influence. 

Treatment. — This  is  only  symptomatic  and  palliative.  Electricity 
may  be  applied  to  the  wasted  muscles  and  to  the  spine.  The  drugs 
used  are  calculated  to  exert  a  tonic  action  on  the  nervous  system,  and 


THE    PROGRESSIVE    MUSCULAR   ATROPHIES 


529 


Fig.  73. — Pseudomuscular  hypertrophy. 


34 


Fig.  74. — Pseudomuscular  hypertrophy. 


530 


THE    PRACTICE    OF    PEDIATRICS 


include  iron,  arsenic,  quinin,  and  strychnin.     Mercury  and  potassium 
iodid  may  be  tried  in  cases  of  possible  syphilitic  origin. 

The  Progressive  Amyotrophies  (Primary  Muscular  Dystrophies) 
These  include  three  types: 

1.  Pseudomuscular  hypertrophy  (Figs.  72,  73,  74). 

2.  Progressive  muscular  atrophy  of  Erb' s  juvenile  type,  or  the  scapulo- 
humeral type. 

3.  Infantile  myopathy  of  the  facioscapulohumeral  type,  or  Landouzy- 
Dejerine  type. 

Etiology. — In  these  cases  there  is  very  frequently  definite  evidence 
of  heredity.  With  the  exception  of  the  juvenile  dystrophy  of  Erb, 
which  occurs  most  frequently  in  early  youth,  these  conditions  begin  to 
develop  before  puberty,  usually  between  the  third  and  tenth  years. 
Pseudomuscular  hypertrophy  is  more  common  in  boys  than  in  girls, 
yet  is  apparently  transmitted  through  the  maternal  parent.  While 
in  many  instances  the  first  symptoms  of  weakness  follow  an  acute  ill- 
ness, it  is  doubtful  whether  trauma  and  acute  diseases  are  truly  causa- 
tive factors. 

Pathology. — According  to  Erb,  the  muscular  changes  are  essentially 
due  to  trophic  disturbances.  In  spite  of  this  there  are  no  demonstrable 
primary  lesions  in  the  nerves  or  spinal  cord.  In  the  muscles  them- 
selves there  is  a  complex  degenerative  atrophy  which  is  characterized 
by  a  preliminary  increase  in  the  size  of  the  muscle-fibers  and  the  num- 
ber of  nuclei,  followed  by  disintegration  of  these  fibers,  increase  of  con- 
nective tissue,  and  lipomatosis.  Although  the  degeneration  is  at- 
tended by  hypertrophy,  the  end-result  is,  therefore,  atrophy. 

Symptoms. — These  have  been  conveniently  outlined  by  Sachs  as 

follows:* 

TYPES  OF  PRIMARY  DYSTROPHIES 


Muscular  Pseudo- 
hypertrophy 


Juvenile  Form  op 
Progre8si-\^  Muscu- 
lar Atrophy  (Erb's 
Type) 


Type  Landouzy- 

D^J^RINE 


Part  first  affected . 

Distribution  of 
hypertrophy. .  .  . 


Distribution  of 
atrophy 


Parts  remaining  nor- 
mal  


Legs  (calves). 

Calves,  rarely 
thighs. 


Thighs,  deep  mus- 
cles of  back, 
shoulder,  and 
scapular  muscles. 
Calves  during 
later  period;  at 
that  time  also 
general  atrophy. 

Face,  forearm  and 
hand,  except  in 
last  stages. 


Shoulder-gi  rdle . 

Muscles  around 
shoulder  -  girdle 
and  pelvic  girdle. 

Thighs,  deep  mus- 
cles of  back,  up- 
per arm.  Hyper- 
trophied  parts 
may  become  atro- 
phic in  later  stage. 


Face,  forearm,  hand 
and  leg  muscles, 
except  in  last 
stages. 


Face  and  shoulder- 
girdle. 
None. 


Face  muscles,  in- 
cluding lips  and 
orbicularis  palpe- 
brarum ;  shoulder 
and  scapular  m.us- 
cles. 


Forearm,  hand, 
and  legs,  and  deep 
muscles  of  back. 


*  Sachs'   Nervous   Diseases  of  Children,  p.  421. 


EPILEPSY  531 

The  "waddling  gait,"  difficulty  in  rising  from  the  floor  (Fig.  72), 
and  large,  hard  calf  muscles  constitute  the  most  prominent  features 
of  the  pseudo-hypertrophic  form.  The  "myopathic  face"  distin- 
guishes the  Landouzy-Dejerine  type. 

In  all  the  forms  there  are  no  fibrillary  twitchings  and  no  complete 
reactions  of  degeneration.  The  reflexes  may  be  normal.  As  the  pa- 
ralysis progresses  they  are  diminished. 

Diagnosis. — The  primary  muscular  dystrophies  are  not  often  con- 
founded with  other  diseases.  A  consideration  of  the  history,  together 
with  a  study  of  the  electric  and  mechanical  behavior  of  the  affected 
muscles,  will  usually  render  easy  the  distinction  between  a  case  of 
amyopathy  and  one  of  amyotrophy. 

Course  and  Prognosis, — These  cases  extend  over  a  period  of  many 
years,  usually  terminating  in  death  from  some  secondary  disease. 

Treatment. — Orthopedic  measures  designed  to  correct  existing  de- 
formities and  complement  the  action  of  partially  degenerated  muscles 
afford  the  best  results.  Moderate  massage  and  judicious  use  of  elec- 
tricity and  exercise  are  of  value.  Further  treatment  consists  only  in 
the  maintenance  of  nutrition  and  the  administration  of  drugs  to  relieve 
temporary  symptoms  as  these  may  arise. 

EPILEPSY 

"Epilepsy,"  declares  Spratling,  "is  the  strangest  disease  in  human 
history.  It  respects  no  race,  no  class,  no  age,  no  occupation.  It  may 
be  in  the  infant  at  birth  or  delayed  till  extreme  old  age,  even  ninety 
years  or  more."  Some  of  the  most  notable  characters  in  history^  in- 
cluding Caesar  and  Napoleon,  are  reported  to  have  been  its  victims, 
and  the  existence  of  the  affection  in  very  remote  times  is  proved  by  the 
ancient  descriptions  of  morbus  sacer  and  morbus  comitialis.  The  term 
"falling  sickness"  best  corresponds  to  Lucretius'  portrayal  of  how  the 
patient,  "struck  as  with  lightning,"  drops;  while  morbus  Herculeus 
might  well  characterize  the  second  stage  of  a  severe  seizure. 

Today,  in  spite  of  a  growing  knowledge  of  contributory  causes, 
most  potent  of  which  are  heredity  and  alcoholism  in  the  parents,  we 
are  still  ignorant  of  the  essential  nature  of  the  disease.  Statistics 
would  serve  to  show  that  alcoholism  in  the  parents  is  an  underlying 
factor  in  many  cases  of  epilepsy.  Woods  reports  7  cases  of  epilepsy 
in  children  which  he  traced  to  single  alcoholic  intoxication  on  the  part 
of  one  or  both  parents,  otherwise  teetotalers.  He  quotes  Dejerine 
who  stated  that  51.5  per  cent,  of  alL  cases  in  children  are  due  to 
parental  alcoholism  and  but  21  per  cent,  to  parental  epilepsy,  also 
Binswanger  of  Germany  who  declares  of  epileptics  "made  in  Germany  " 
22  per  cent  had  their  origin  in  chronic  parental  inebriations  while  but 
11  per  cent,  were  due  to  parental  epilepsy.  Wood  believes  that  it  is 
not  so  much  chronic  drunkenness  as  drunkenness  at  the  time  of  concep- 
tion that  causes  the  transmittal  of  an  often  overwhelming  neurosis 
to  offspring. 

Statistics  further  show  that  from  one  to  three  persons  in  every 


532  THE    PRACTICE    OF    PEDIATRICS 

thousand  throughout  Europe  and  America  are  epileptics,  the  propor- 
tion of  males  being  slightly  in  excess. 

Lengthy  discussions  will  be  found  in  works  on  neurology  relating 
to  various  features  of  the  disease.  To  these  works  the  reader  is  re- 
ferred, although  in  them  he  will  find  but  little  that  is  illuminating. 

Epilepsy  is  not  a  disease  of  infancy,  and  while  cases  have  been  re- 
ported as  occurring  in  children  under  one  year  of  age,  such  occurrences 
are  unquestionably  very  rare.  I  have  treated  a  large  number  of  chil- 
dren who  have  had  infantile  convulsions  and  who  never  developed  epi- 
lepsy. Neurologists  are  inclined  to  attribute  a  varying  percentage  of 
the  cases  of  epilepsy  to  infantile  convulsions,  dentition  convulsions, 
etc.  The  neurologist  does  not  know  of  the  hundreds  of  such  cases 
seen  by  pediatrists  and  practitioners  in  which  there  is  never  further 
trouble.  While  a  certain  percentage  of  epileptics  may  have  had  con- 
vulsions in  infancy,  a  much  larger  percentage  of  infants  have  convul- 
sions without  further  trouble. 

I  agree  with  Koplik,  who  states,  "Epilepsy  bears  no  demonstrable 
relation  to  infantile  convulsions.  The  fact  that  the  patients  developed 
the  disease  at  an  early  age  helps  in  no  way  to  explain  the  condition, 
and  the  underlying  factors  in  epilepsy  are  the  same  regardless  of  the 
age  of  the  patient.  Thus  what  constitutes  epilepsy  is  yet  to  be  deter- 
mined. Various  brain  lesions  have  been  found  in  association  with  epi- 
lepsy, and  to  them  the  seizures  have  been  attributed,  and  yet  these 
lesions  and  more  pronounced  involved  areas  are  found  at  postmortem 
without  the  occurrence  of  epilepsy." 

Types.— Clinically,  epilepsy  may  be  divided  into  two  types,  yetit 
mal  and  grand  mal. 

Petit  Mal. — This  form  may  occur  independently,  or  in  association 
with  grand  mal.  One  person  may  be  subject  to  both  kinds  of  attacks. 
In  petit  mal  there  is  a  temporary  or  partial  loss  of  consciousness  with- 
out convulsion.  The  child  may  simply  hesitate  in  his  play  and  grow 
pale.  There  is  a  dull  look  in  the  eyes,  then  the  attack  is  over,  and  the 
play  is  resumed.  The  attack  may  manifest  itself  in  what  corresponds 
to  a  fainting  attack,  in  which  the  child  loses  color  and  sinks  to  the  floor, 
but  is  normal  in  a  few  moments. 

Illustrative  Cases. — A  girl  two  years  old  with  a  good  family  history  had  two 
"fainting  attacks"  on  two  successive  days.  The  attacks  apparently  consisted  of  a 
temporary  clouding  of  the  mentality,  with  a  tendency  to  fall.  During  the  past 
two  years  the  child  has  had  six  of  these  attacks. 

In  a  child  treated  several  years  ago  the  only  signs  of  the  disease  were  manifested 
by  a  sudden  cessation  of  play,  when  the  patient  would  gaze  into  space  for  a  few 
seconds  only,  with  dilated,  fixed  pupils  and  a  vacant  stare. 

Grand .  Mal. — The  epileptic  attack  is  in  most  cases  preceded  by 
prodromal  symptoms,  known  as  ^Hhe  aura,'''  which  consists  of  a  warning 
by  which  the  patient  knows  the  attack  is  coming  on.  The  aura  is  de- 
scribed as  a  peculiar  sensation  felt  in  some  portion  of  the  body  before 
the  attack  and  at  no  other  time. 

Illustralive  Cases. — A  boy  patient  had  what  he  described  as  a  pain  in  the  side. 
It  was  always  in  the  same  side  and  the  area  of  the  pain  was  not  larger  than  a  silver 


EPILEPSY  533 

dollar.     Numbness,  tingling,  and  a  feeling  of  soreness  in  the  stomach  have  all  been 
described  as  constituting  the  aura. 

Another  boy  patient  of  eight  years  could  always  anticipate  an  attack  through  a 
feeling  which  he  could  not  describe  in  the  right  leg,  and  which  traveled  up  to  the 
abdomen. 

In  grand  mal  there  are  loss  of  consciousness,  dilatation  of  the 
pupils,  foaming  at  the  mouth,  stertorous  breathing,  and  biting  of  the 
tongue  due  to  spasm  of  the  jaw  muscles.  The  muscle  spasm  gradu- 
ally lessens,  consciousness  slowly  returns,  and  the  patient  passes 
into  a  deep  sleep.  Every  variation  of  the  above  symptoms  may  be 
encountered. 

The  nature  of  the  convulsive  movement  may  help  to  determine  the 
nature  of  the  disease.  Localization  of  spasm  in  one  portion  of  the 
body  or  one  set  of  muscles  indicates  some  distinct  local  lesion  in  the 
brain. 

Diagnosis. — The  diagnosis  of  epilepsy  is  not  difficult.  Repeated 
convulsions  after  the  age  of  infancy  are  always  epileptic.  An  infant 
may  have  repeated  convulsions  and  yet  not  have  epilepsy.  I  have 
seen  this  time  and  again.  However,  if  a  child  two  or  more  years  of 
age  has  repeated  convulsions,  even  at  intervals  of  several  months, 
the  condition  must  be  looked  upon  as  epilepsy. 

A  girl  of  fifteen  had  a  nocturnal  attack.  She  is  now  twenty-seven. 
There  have  been  five  seizures  and  all  at  night.  Cases  of  this  nature 
constitute  epilepsy  just  as  truly  as  though  the  attacks  had  occurred  in 
as  many  months. 

Diagnosis. — Diagnosis  in  children  is  easy,  because  children  do  not 
have  repeated  innocent  fainting  spells.  Neither  are  hysteric  seizures 
at  all  common,  and  when  they  do  occur  they  simulate  epilepsy  to  such 
a  slight  degree  that  a  differentiation  is  superfluous. 

Prognosis. — The  prognosis  of  epilepsy  as  to  a  cure  is  bad.  The 
outlook  for  many  of  these  is  hopeless ;  nevertheless,  under  a  regime  in- 
volving right  living,  proper  diet,  and  avoidance  of  excitement,  many 
epileptics  undergo  but  little  inconvenience.  The  young  woman  men- 
tioned above  has  not  had  an  attack  in  twelve  years. 

There  are  plenty  of  examples  in  history  of  men  who  were  epileptics 
who  have  gained  marked  distinction. 

Treatment. — In  the  management  of  epilepsy  practically  all  we  can 
hope  to  do  is  to  diminish  the  frequency  of  the  attacks  which  character- 
ize the  disease,  whether  it  be  grand  mal  or  petit  mal.  Proper  nutrition, 
rational  habits  of  living,  and  pleasant  outdoor  occupations  are  of  in- 
estimable service  in  the  management  of  the  epileptic.  The  manage- 
ment which  has  served  me  best  has  been  directed,  first,  along  general 
and  hygienic  fines;  secondly,  it  has  involved  the  use  of  drugs.  Our 
aim  should  be  to  make  the  patient  physically  as  normal,  as  vigorous, 
and  as  resistant  to  attacks  as  lies  in  our  power. 

General  Considerations. — Visual  defects,  enlarged  tonsils,  adenoids, 
phimosis,  and  irritant  skin  lesions  must  all  be  corrected  before  bene- 
ficial results  are  to  be  expected  from  any  line  of  treatment.  The  pa- 
tient should  then  be  placed  under  the  best  environment  permitted  by 


534  THE    PRACTICE    OF    PEDIATRICS 

his  station  in  life.  Outdoor  life,  sports,  and  games  are  to  be  encour- 
aged, always  within  the  bounds  of  moderation.  The  child  should  sleep 
in  a  cool  room  with  the  freest  possible  ventilation  at  all  seasons  of  the 
year.  If  he  is  a  school-child,  he  should,  if  possible,  be  instructed  at 
home  and  given  short  sessions  with  easy  studies.  In  work  or  play  the 
patient  should  never  be  allowed  to  reach  the  point  of  mental  or  phys- 
ical fatigue.  This,  to  my  mind,  is  most  important.  Emotional  plays 
at  the  theater  and  exciting  amusements  elsewhere  are  forbidden. 

Diet  and  Bowel  Function. — The  diet  is  to  be  adjusted  to  the  child's 
digestive  capacity.  A  diet  suitable  for  the  age  is  given,  just  as  for  the 
normal  child  (p.  105),  meat  being  allowed  only  once  a  day.  As  intes- 
tinal indigestion  and  toxemia  from  intestinal  sources  are  unquestion- 
ably important  etiologic  factors  in  causing  a  recurrence  of  the  seizures, 
careful  attention  to  the  bowel  function  and  diet  are  most  important" 
features  of  the  treatment.  The  epileptic  patient  under  my  care  is 
never  allowed  to  pass  over  twenty-four  hours  without  an  evacuation  of 
the  bowels,  and  if,  in  the  opinion  of  those  in  charge,  the  evacuation  is 
not  as  copious  as  usual,  an  enema  is  given.  If  there  is  a  suggestion  of 
constipation,  the  treatment  with  the  oil  enemata,  or  other  means  as 
recommended  for  chronic  constipation  (p.  241),  is  instituted.  In  cases 
in  which  heredity  and  toxic  influences  prevail,  the  importance  of  at- 
tention to  the  diet  and  habits  of  life  cannot  be  overestimated.  When 
there  is  a  focal  lesion,  attention  to  the  details  of  living  will  have  less 
influence,  but  always,  surely,  some  influence,  in  diminishing  the  fre- 
quency and  severity  of  the  seizures  by  establishing  a  more  vigorous 
physical  resistance. 

Colony  Management. — During  the  past  half-century  the  colony 
treatment,  which  began  in  German^  with  a  successful  private  attempt 
to  house  four  patients  separately,  has  become  widespread,  and  at  pres- 
ent this  method  promises  the  most  practical  and  far-reaching  results. 
When  parents  are  unable  to  give  the  patient  suitable  attention  at  home, 
I  urge  that  he  be  placed  in  one  of  the  excellent  institutions  devoted  to 
the  care  of  epileptics,  where  the  whole  manner  of  life  is  adjusted  and 
regulated  with  one  object  in  view.  The  colony  management  offers 
advantages  that  cannot  be  secured  elsewhere. 

Drugs. — There  are  few  drugs  in  the  pharmacopeia,  particularly 
those  of  a  sedative  nature,  that  have  not  been  used  at  one  time  or 
another  in  the  treatment  of  epilepsy.     The  bromids  unquestionably  ' 
serve  our  purpose  in  controlling  the  seizures  better  than  does  any  other  i 
form  of  medication.     The  size  of  the  dose  is  variable.     Because  of 
their  peculiarly  depressing  effects  upon  the  child's  mental  condition 
the  bromids  should  be  given  in  as  small  quantities  as  are  compatible  ' 
with  the  beneficial  result  desired — a  diminution  in  the  number  of  the 
convulsions.     To  a  child  ten  years  old,  10  grains  of  sodium  bromid 
ordinarily  may  be  given,  well  diluted,  in  one-half  glass  of  water  after 
meals.     The  amount  may  be  increased  or  diminished  as  the  progress 
of  the  case  demands.     If  the  convulsions  are  nocturnal,  in  a  child  of 
ten  years,  large  doses — from  20  to  30  grains — should  be  given  at  bed- 


ACUTE    POLIOMYELITIS    (iNFANTILE    PARALYSIs)  535 

time.  In  the  event  of  the  discontinuance  of  the  drug  to  the  point 
where  it  is  given  but  once  a  day,  the  time  selected  should  be  bedtime. 
If  there  is  continued  improvement  under  the  bromid,  it  may  be  given 
on  alternate  nights,  and  finally  every  fourth  night. 

As  ocular  defects  may  be  important  factors  in  causing  epilepsy, 
every  child  with  epilepsy  should  have  the  eyes  examined  by  a  com- 
petent oculist. 

Illustrative  Case. — I  have  still  under  my  care  the  young  woman  already  twice 
referred  to.  The  first  convulsion  occurred  at  the  fifteenth  year.  It  was  a  typical 
nocturnal  seizure.  Fifteen  grains  of  bromid  with  5  drops  of  the  tincture  of  bella- 
donna were  given  three  times  daily  for  three  months,  when  the  bromid  was  reduced 
to  30  grains  daily.  This  was  continued  for  one  month,  when  a  death  occurred  in 
the  family  which  doubtless  helped  to  incite  a  second  attack.  At  this  time,  as  the 
patellar  reflex  was  scarcely  perceptible  and  the  bromid  rash  was  considerable,  the 
drug  was  discontinued.  At  the  end  of  two  months  the  daily  dosage  was  placed  at 
20  grains,  with  10  drops  of  tincture  of  belladonna.  This  was  continued  for  four 
weeks,  when  there  was  a  third  attack,  without  any  apparent  cause  of  an  exciting 
nature  beyond  the  fact  that  the  patient  had  allowed  herself  to  become  obstinately 
constipated.  This  was  her  last  attack.  Twelve  years  have  since  intervened 
without  a  sign  and  without  treatment  for  three  years. 

ACUTE  POLIOMYELITIS  (INFANTILE  PARALYSIS) 

Anterior  poliomyelitis  is  an  infectious  and  a  transmissible  disease. 

Etiology. — From  the  brain  and  spinal  cord  of  human  cases  of 
poliomyelitis,  as  well  as  from  experimental  cases  of  the  disease  in 
monkeys,  Flexner  and  Noguchi*  cultivated,  by  anaerobic  methods,  a 
globular  or  globoid  body  smaller  than  any  known  coccus,  0.15  to  0.3)U 
in  size,  and  staining  pale  reddish- violet  by  Giemsa  's  solution.  Noguchi 
also  demonstrated  identical  bodies  in  films  prepared  directly  from 
the  nervous  tissues. 

These  cultures,  when  inoculated  into  monkeys,  have  caused  typical 
experimental  poliomyelitis. 

The  virus  resists  freezing  for  a  period  of  forty  days,  and  drying  for 
seven  days,  but  becomes  inert  after  exposure  to  45°  to  50°C.  for  half  an 
hour. 

Pathology. — The  lesions  produced  by  the  virus  of  poliomyelitis  are, 
naturally,  most  marked  in  the  nervous  system,  but  they  are  present 
in  other  viscera  as  well.  In  the  nervous  system  the  gross  lesions  are 
not  always  very  pronounced.  They  may  appear  in  the  spinal  cord, 
pons,  medulla,  and  cerebrum,  and  consist  of  congestion  and  minute 
hemorrhages,  chiefly  into  the  gray  matter.  The  lesions  of  the  spinal 
cord  are  not  confined  to  the  anterior  horn.  On  microscopic  examination 
the  most  marked  lesions  are  found  in  the  cord  at  the  level  corresponding 
to  the  most  completely  paralyzed  muscle  groups.  The  meninges  show 
perivascular  infiltration  with  round-cells,  chiefiy  lymphocytes.  The 
infiltration  extends  along  the  nerve  roots  and  penetrates  between  the 
fibers.  In  the  gray  and  white  matter  of  the  spinal  cord  there  are 
focal  lesions  consisting  of  edema,  perivascular  cellular  infiltration, 
numerous  hemorrhages,  and  degeneration  of  the  nerve-cells  and  fibers. 
The  anterior  horns  of  the  gray  matter  show  more  marked  lesions  than 
*  "Jour.  Amer.  Med.  Assoc,"  1913,  Ix,  p.  362. 


536  THE    PRACTICE    OF    PEDIATRICS 

do  the  posterior  horns,  the  nerve-cells  being  sometimes  replaced  by 
leukocytes.  The  cells  in  a  segment  are  always  unequally  involved. 
Similar  focal  lesions  may  be  present  in  the  medulla,  pons,  and  cere- 
brum. The  intervertebral  ganglia  show  infiltration  with  lymphocytes 
between  the  nerve-cells  and  fibers,  and  some  ganglion-cells  show  de- 
generation and  necrosis. 

The  primary  lesion  seems  to  be  in  the  meninges,  and  the  cellular 
exudate  about  the  vessels,  with  their  resulting  partial  destruction, 
leads  to  secondary  lesions  in  the  nervous  tissue  itself. 

In  other  viscera  the  lesions  consist  of  hypertrophy  of  the  lymphoid 
tissue,  including  that  of  the  tonsils,  the  thymus  gland,  the  super- 
ficial and  deep  lymphatic  glands,  the  small  intestines,  and  the  spleen. 
There  are  also  minute  focal  necroses  in  the  liver.* 

Cerebrospinal  Fluid. — The  cerebrospinal  fluid  shows  changes  varying 
with  the  stage  of  the  disease.  The  cell  count  is  almost  always  in- 
creased, being  highest  during  the  early  days  of  the  attack,  and  falling 
off  progressively  as  the  attack  goes  on,  reaching  the  normal  in  two  weeks, 
or  less.  In  the  majority  of  cases  the  fluid  shows  lymphocytes  and  large 
mononuclear  cells  only,  but  the  polymorphonuclear  cells  may  amount 
to  90  per  cent,  of  the  total. f  The  globulin  content  is  increased,  more 
so  during  the  second  week  than  the  first.  It  may  remain  above  the 
normal  for  seven  weeks  or  more  but,  during  the  chronic  stage  of 
the  disease,  it  tends  to  fall  to  normal.  Draper  and  Peabody  also  found 
that  the  blood  shows  a  constant  marked  leukocytosis,  sometimes  as 
high  as  30,000.  The  polymorphonuclear  leukocytes  are  increased 
10  to  15  per  cent.,  while  the  lymphocytes  are  diminished  from  15  to 
20  per  cent. 

Blood  Findings  in  Poliomyelitis. — The  blood  was  studied  by 
Peabody,  Draper  and  Dochez  in  71  cases  of  poliomyelitis.  In  only 
one  case  did  they  find  a  leukopenia.  In  70  cases  there  was  a  constant 
and  marked  leukocytosis,  sometimes  ranging  as  high  as  30,000. 

During  the  preparalytic  stage  the  total  leukocyte  count  may  be 
normal,  though  there  is  a  tendency  toward  an  increase  with  more 
polymorphonuclears  and  less  lymphocytes  than  during  health. 

During  the  first  and  second  weeks  of  the  disease  the  leukocytes 
vary  from  12,000  to  24,000  with  an  average  of  18,000.  The  poly- 
morphonuclears are  increased  15  to  20  per  cent,  and  the  lymphocytes 
diminished  15  to  20  per  cent.  Transitional  and  large  mononuclear  cells 
show  no  change. 

The  leukocytosis  continues  for  weeks,  the  average  of  9  cases  in  the 
seventh  week  having  been  17,250  leukocytes. 

The  youngest  children  showed  the  highest  leukocytosis  and  the 
largest  number  of  polymorphonuclear  cells. 

Transmission. — Recent  advances  in  our  knowledge  of  the  etiology 
and  pathology  of  anterior  poliomyelitis  date  from  the  work  of  Land- 
steiner  and  Papper  in  1909.     They  succeeded  in  inoculating  monkeys 

*  Flexner,  Peabody,  and  Draper:  "Jour.  Amer.  Med.  Assoc,"  1912,  p.  109. 
t  Draper  and  Peabody:  "Amer.  Jour,  of  Dis.  of  Children,"  vol.  iii,  1912. 


ACUTE    POLIOMYELITIS    (INFANTILE    PARALYSIS)  537 

intraperitoneally  with  material  obtained  from  a  fatal  case  of  the  dis- 
ease in  a  child.  Knoepfelmacher  also  succeeded  in  producing  polio- 
myelitis in  a  monkey  by  the  inoculation  of  human  material,  but  these 
workers  were  not  able  to  transmit  the  disease  from  monkey  to  monkey. 
Flexner  and  Lewis  succeeded  in  doing  this  without  difficulty,  using  the 
intra-cerebral  method  of  inoculation  and  carrying  their  strains  of  virus 
through  many  generations.  Flexner  and  Lewis  were  also  able  to  trans- 
mit poliomyelitis  to  monkeys  by  means  of  subcutaneous  and  intrave- 
nous inoculation,  though  not  in  all  cases  were  such  experiments  suc- 
cessful. On  the  other  hand,  intranasal  inoculation  in  monkeys  gives 
results  that  are  always  positive,  while  intraneural  inoculation,  as 
practised  by  Leiner  and  v.  Weisner,  is  less  uniformly  successful. 

The  Nasal  Mucous  Membrane. — Flexner  and  Lewis  showed  that  the 
nasopharyngeal  mucosa  is  a  regular  site  of  elimination  for  the  virus  of 
poliomyelitis  in  monkeys  experimentally  inoculated  with  the  disease, 
and  Landsteiner,  Levaditi,  and  Pastia  demonstrated  the  same  method 
of  excretion  of  the  virus  in  a  human  patient  dying  during  the  acute 
stage  of  poliomyelitis.  Flexner  and  Clark  also  found  the  virus  in  the 
tonsils  or  nasal  mucosa  of  human  cases,  and  Flexner  has  suggested 
that  "the  nasopharynx  acts  in  human  beings  as  the  portal  of  entry  of 
the  virus  into  the  central  nervous  system,  as  well  as  its  source  of  dis- 
semination to  other  human  beings."  In  monkeys,  and  also  probably 
in  human  beings,  the  virus  may  disappear  from  the  nervous  system 
and  from  the  tonsils  and  nasopharyngeal  mucosa  in  from  eight  to  ten 
days  after  the  onset  of  the  paralysis,  or  it  may  persist  there  for  three 
or  four  weeks.  The  observation  of  Osgood  and  Lucas,  who  found  that 
the  nasopharyngeal  mucosa  of  monkeys  was  still  infectious  five  months 
after  the  acute  stage  of  an  attack  of  poliomyelitis,  would  seem  to  be 
exceptional  and  to  indicate  that  chronic  carriers  of  poliomyelitis  may 
develop. 

The  Virus. — The  virus  of  poliomyelitis  is  regularly  present  in  the 
central  nervous  system,  and  less  frequently  in  the  tonsils,  nasopharyn- 
geal mucous  membrane,  and  mesenteric  lymph-nodes.  It  has  not  been 
found  in  the  large  viscera  nor  in  the  blood.  The  spinal  fluid  from  a 
human  case  of  poliomyelitis  is  capable  of  producing  the  disease  when 
inoculated  into  a  monkey. 

It  has  been  pointed  out  that  epidemics  of  poliomyelitis  develop  along 
the  route  of  human  travel.  Flexner  and  Clark  showed  that  stable- 
flies  may  harbor  the  virus  on  their  bodies  for  a  period  of  at  least  forty- 
eight  hours,  and  that  it  may  remain  in  their  viscera  for  the  same  length 
of  time. 

Immunity. — Flexner  and  Lewis  proved  that  monkeys  which  have 
recovered  from  poliomyelitis  are  immune  to  further  attacks  of  the  dis- 
ease. They  further  showed  that  the  blood  of  these  immune  animals 
contains  neutralizing  principles.  Netter  and  Levaditi  demonstrated 
the  presence  of  such  neutralizing  principles  in  the  blood  of  an  abortive 
case  occurring  in  a  child. 

Type  of  Cases. — For  clinical  purpose  poliomyelitis  may  be  divided 


538  THE    PRACTICE    OF    PEDIATRICS 

into  three  types:  the  abortive,  in  which  no  paralysis  occurs;  the  cerebral, 
representing  the  rare  cases  with  resulting  spastic  paralysis;  and  the 
bulbar  spinal  group,  which  comprises  all  cases  with  lesions  in  the  lower 
motor  neuron,  and  flaccid  paralysis.* 

Seasonal  Influences. — While  the  disease  may  appear  at  any  season 
of  the  year,  a  vast  majority  of  the  cases  develop  between  July  and 
October. 

Age  Incidence. — Although  poliomyehtis  is  a  disease  of  childhood, 
cases  occurring  in  adults  are  not  at  all  uncommon.  In  some  recent 
epidemics  adults  have  numbered  as  high  as  20  per  cent,  of  the  cases. 
In  the  1907  New  York  epidemic  the  youngest  patient  reported  was  two 
weeks  old.  The  most  susceptible  age  is  from  the  eighteenth  month  to 
the  sixth  year.     Males  are  affected  more  frequently  than  females.   • 

Period  of  Incubation. — From  five  to  fourteen  days  is  generally 
accepted  as  the  period  of  incubation.  This  observation  is  based  upon 
the  results  of  clinical  and  laboratory  investigations. 

Symptoms. — As  in  all  infectious  diseases,  the  symptoms  vary 
widely.  In  a  great  majority  of  the  cases  there  are  decided  prodromal 
symptoms. 

The  most  constant  early  symptom  is  fever.  Usually  there  is  a 
sharp  rise  of  temperature — in  a  number  of  instances  to  105°  or  106°F. 
The  duration  of  the  fever  is  variable — ^from  one  day  to  a  week.  In 
some  cases  there  will  be  a  sharp,  sudden  rise  and  rapid  fall.  In  a  few 
there  is  slight  temperature,  and  in  others  none  at  all.  In  our  two 
recent  epidemics  of  1907  and  1916  gastro-intestinal  symptoms  were 
very  prominent  in  a  large  number  of  cases.  Thus  there  was  vomiting 
and  diarrhea  or  a  sharp  attack  of  vomiting.  A  peculiar  feature  of  my 
cases  has  been  that  the  severity  of  the  gastro-intestinal  symptoms  has 
borne  no  relation  to  the  degree  of  the  resulting  paralysis.  Ordinarily 
the  paralysis  is  not  noticed  until  the  third  or  fourth  day  of  the  prodromal 
stage.  Pain  and  hyperesthesia  are  very  prominent  symptoms  in  many 
cases.  The  patient  begs  not  to  be  disturbed;  manipulation  of  the  body 
and  moving  the  limbs  give  rise  to  most  intense  pain. 

The  nervous  manifestations  may  be  very  urgent ;  thus  convulsions, 
apathy  and  stupor  are  not  uncommon  and  the  cases  may  closely  resemble 
acute  cerebro-spinal  meningitis.  In  fact  such  an  error  in  diagnosis  is 
frequently  made.  When  bulbar  involvements  predominate  there  will 
be  facial  or  ocular  paralysis,  disturbance  of  speech  and  deglutition,  and 
paralysis  of  the  respiratory  muscles.  Eleven  fatal  cases  in  private 
work  which  came  under  my  observation  in  the  1916  epidemic  were  of 
this  type.  In  three  cases  the  paralysis  was  limited  to  the  bladder. 
One  case  was  of  the  very  unusual  ascending  Landry  type.  The  feet 
were  first  involved  and  then  the  trunk,  arms  and  neck.  The  child 
recovered  after  a  long  illness.  Early  in  the  disease,  before  the  paralytic 
stage,  the  reflexes  may  be  exaggerated.  The  paralysis  appears  from 
two  to  four  days  after  the  acute  onset.  It  may  involve  an  entire 
limb,  or  be  limited  to   muscle  groups  irregularly   distributed.     The 

*  Draper,  Peabody,  and  Dochez:  "  Rockefeller  Institute  Reports,"  No.  iv. 


ACUTE    POLIOMYELITIS    (iNFANTILE    PARALYSIs)  539 

extent,  degree,  and  permanency  of  the  paralysis  depend  upon  the 
severity  of  the  lesion  in  the  cord.  Lesions  in  the  lumbar  enlargement 
are  the  most  frequent  and  cause  the  greatest  number  of  cases  of 
paralysis.  Involvement  of  the  cervical  enlargement  causes  the  next 
largest  number  of  cases.  Wickman  reported  the  distribution  of  the 
lesions  in  868  cases  as  follows: 

1 .  One  or  both  legs 353 

2.  One  or  both  arms 75 

3.  Combination  of  arms  and  legs 152 

4.  Combination  of  legs  and  trunk  muscles 85 

5.  Combination  of  arms  and  trunk  muscles 10 

6.  Trunk  muscles  alone 9 

7.  Paralysis  of  "the  whole  body" 23 

8.  Ascending  paralysis 32 

9.  Descending  paralysis 13 

10.  Combination  of  spinal  and  cranial  nerves 34 

11.  Cranial  nerves  alone 22 

12.  Localization  of  paralyses  not  given 60 

In  about  one-half  of  the  cases  the  paralysis  is  limited  to  the  legs. 
The  cerebral  type,  in  which  a  differentiation  is  difficult,  presents 
clinically  a  symptom-complex  which  distinguishes  it  from  the  foregoing. 
This  condition  was  designated  as  polioencephalitis  by  Striimpell.  The 
onset  in  these  cases  is  with  fever,  convulsions,  vomiting,  strabismus, 
and  coma.     The  reflexes  are  usually  exaggerated. 

Imbecility,  epilepsy,  and  spastic  paralysis  may  be  the  outcome. 
Cases  are  often  designated  as  cerebral  which  strictly  do  not  belong  to 
this  type.  In  view  of  the  fact  that  the  infection  is  a  general  one, 
involving  the  entire  nervous  system;  cerebral  symptoms  are  necessarily 
present  in  many  cases.  The  fact  that  these  manifestations  promptly 
disappear  means  that  no  permanent  lesions  were  present,  and  that  the 
brain  shared  in  the  toxic  systemic  effects. 

That  there  are  many  cases  of  poliomyelitis  which  do  not  pass  to 
the  paralytic  stage  is  the  opinion  of  all  observers  who  have  seen  many 
cases  of  the  disease.  In  the  epidemics  of  1907  and  1916  several  such 
cases  came  under  my  observation.  Prodromal  symptoms  were  very 
urgent  in  two  patients  who  developed  slight  leg  weakness  and  absence 
of  patellar  reflex.  Both  recovered  in  three  weeks.  In  two  others, 
a  boy  and  girl  in  the  family  of  a  physician,  the  prodromal  symptoms 
were  rather  mild  and  both  developed  a  shght  paralysis  of  short 
duration. 

Wickman  believes  that  over  25  per  cent,  of  the  cases  belong  to  this — 
the  so  called  abortive  type.  There  is  no  apparent  distinction  to  be  made 
between  the  symptomatology  of  the  abortive  cases  and  those  that  go  on  to 
the  development  of  paralysis.  Muller*  believes  that  the  abortive  cases 
out-number  those  of  paralysis.  This  view  receives  striking  support  from 
the  recent  demonstration  of  typical  visceral  lesions,  indicating  that  there 
is  a  general  systemic  infection.  With  such  pathologic  findings,  symp- 
toms such  as  fever  and  malaise  are  reasonably  to  be  expected.  It  may 
be  that  the  abortive  cases  are  those  in  which  this  general  process  is 
*  Draper,  Peabody,  and  Dochez:  "Rockefeller  Institute  Monograph,"  No.  iv. 


540  THE  PRACTICE  OF  PEDIATRICS 

present,  but  in  which  the^nervous  system  has  been  spared.  Netter  and 
Levaditi*  have  demonstrated  that  the  serum  of  abortive  cases  neutral- 
izes the  virus  in  vitro,  just  as  does  the  serum  of  the  patients  that  develop 
paralysis.  It  is  quite  probable  that  in  the  past  many  of  the  abortive 
cases  have  not  been  recognized,  and  in  certain  cases  at  least,  the  appar- 
ent immunity  of  adults  may  be  dependent  upon  such  a  previous,  un- 
recognized attack.  That  the  neutralizing  substance  in  the  blood  may 
persist  for  a  long  period  following  an  attack  of  the  disease,  and  probably 
immunity  be  present  as  well,  is  shown  by  the  case  of  a  man  who  had 
been  paralyzed"  thirty  years  before,  and  whose  serum  still  protected 
a  monkey  from  the  virus. 

Course. — Following  the  prodromal  symptoms,  flaccid  paralysis, 
loss  of  knee-jerk,  and  atrophy  appear.  The  paralyzed  part  becomes 
smaller  than  the  corresponding  limb  or  muscle  group.  The  limb  be- 
comes cooler  than  the  normal.  Subluxation  of  a  joint,  due  to  re- 
laxation of  the  ligaments,  is  not  an  uncommon  occurrence  in  cases  in 
which  there  is  extensive  paralysis. 

Electric  Reactions. — During  the  onset  of  the  disease  the  electric 
irritability  of  the  affected  muscles  and  nerves  is  increased.  After  two  or 
three  days,  however,  these  nerves  fail  to  respond  to  stimulation,  and 
the  paralyzed  muscles  contract  only  under  the  galvanic  current,  show- 
ing the  typical  reaction  of  degeneration  (an  anodal  opening  contraction 
greater  than  the  kathodal  closure  contraction) .  Galvanic  irritability 
in  the  paralyzed  muscles  may  be  increased  for  several  months,  but 
thereafter  diminishes,  and  after  a  year  or  more  disappears. 

Prognosis. — The  prognosis  in  this  disease  must  cover  not  only  the 
mortality,  but  the  resulting  permanent  paralysis  as  well.  The  mor- 
tality varies  with  epidemics;  roughly  it  may  be  said  to  range  from  5 
to  20  per  cent.  The  younger  the  child,  the  less  the  danger  to  life  is  a 
rule  borne  out  by  experiences  in  many  epidemics.  The  disease  is  more 
fatal  after  the  fifteenth  year.  In  the  Springfield,  Mass.,  epidemic, 
7  patients  were  over  fifteen  years  of  age.  Of  these,  3  died.  In  the 
fatal  cases  death  usually  takes  place  by  the  fifth  day. 

Prognosis  as  regards  permanent  paralysis  is  most  difficult.  Cases 
with  very  severe  prodromal  symptoms  may  have  no  permanent  effects. 
The  degree  of  damage  depends  upon  the  severity  of  the  lesion  in  the 
cord,  and  this  is  impossible  of  demonstration.  I  have  seen  cases  in 
which  the  paralysis  was  complete  make  perfect  recoveries,  and  other 
cases  of  similar  nature,  followed  by  permanent  residual  paralysis.  A 
child  of  eighteen  months  had  complete  paralysis  of  the  neck  muscles 
and  all  four  extremities.  In  this  case  the  outlook  apparently  was 
hopeless,  and  yet  the  child  made  a  perfect  recovery. 

Permanent  paralysis  may  follow  very  mild  prodromal  symptoms. 

The  prognosis  is  further  influenced  by  the  possibilities  of  continued 

treatment.     Many  cases  admit  of  much  improvement  through  properly 

directed    management    continued    over    long   periods.     Among   530 

cases  collected  by  Wickman,  56  per  cent,  were  paralyzed,  44  per  cent. 

*  Netter  and  Levaditi:  "Compt.  rend.  Soc.  de  bioL,"  1910,  Ixviii,  617. 


ACUTE    POLIOMYELITIS    (INFANTILE    PARALYSIS)  541 

cured  after  eighteen  months.     In  Massachusetts  there  were  16.7  per 
cent,  of  complete  recoveries.* 

Communicability. — The  disease  is  communicable  by  personal 
contact;  this  has  been  definitely  proven  under  my  own  observation, 
during  the  present  (1916)  epidemic  in  this  country.  There  had  not 
been  a  case  in  a  certain  New  England  village  for  25  years.  Two 
children  aged  3  and  6  years,  came  to  the  village  from  an  infected  section. 
Both  became  ill  with  digestive  disorders  and  fever  on  the  day  of  their 
arrival.  The  3  year  old  girl  was  kept  in  her  room  and  later  developed 
paralytic  symptoms.  The  older  child  was  ill  but  24  hours — a  typical 
abortive  case.  Among  the  children  who  associated  with  her,  one,  a 
native,  after  6  days  developed  a  fatal  poliomyelitis.  I  could  give  several 
other  personal  observations  proving  beyond  all  doubt  the  communica- 
bility by  contact.  That  the  disease  may  be  carried  by  an  intermediary 
is  yet  to  be  proven. 

Quarantine. — That  the  disease  is  spread  largely  through  undiagnosed 
abortive  cases  is  unquestionable.  Quarantine,  therefore,  should  be 
absolute  of  all  suspected  cases  and  cases  that  have  been  exposed. 
Furthermore,  every  child  who  develops  an  active  illness  with  fever 
and  gastro-intestinal  disturbance  during  an  epidemic  should  be  quaran- 
tined, together  with  those  children  with  whom  he  has  previously 
associated. 

Treatment. — During  the  acute  stage  of  the  involvement  of  the  cord 
our  efforts  count  for  little.  We  order  that  the  child  be  kept  quiet  in 
bed,  that  a  laxative  be  given,  and  that  he  receive  light,  easily  digested 
nourishment;  and  then,  so  far  as  the  immediate  conditions  are  con- 
cerned, we  have  done  our  little,  but  our  all.  I  have  used  the  bromids 
and  ergot  and  urotropin  and  the  iodids  internally,  and  ice-bags  and 
blisters  over  the  spine  at  the  site  of  the  lesion,  and  am  yet  to  be 
convinced  that  they  are  worth  the  indigestion  and  discomfort  they  are 
apt  to  occasion.  That  the  disease  is  due  to  an  infection  is  now  proved, 
and  in  a  given  case  our  hope  must  be  that  the  infection  will  be  mild 
in  character.  The  outcome  is  determined  largely  by  the  severity  of 
the  infection  and  by  the  resistance  of  the  child. 

Human  Serum. — The  intraspinal  use  of  human  serum  from  those 
who  have  recovered  from  poliomyelitis  has  its  advocates, f  My  own 
observations  do  not  warrant  an  endorsement  of  this  form  of  treatment. 

Later  Treatment. — From  ten  days  to  two  weeks  after  the  acute 
stage  has  passed  our  efforts  should  be  directed  toward  maintaining  the 
nutrition  of  the  affected  muscle  or  groups  of  muscles.  This  is  to  be 
done  by  mechanical  means,  electricity,  and  gymnastic  exercises 
(p.  803). 

The  beneficial  action  of  electricity  consists  largely  in  exercising  the 
muscles  no  longer  under  voluntary  control,  and  thus  increasing  their 
circulation  and  nutrition.  The  immediate  object  of  the  electricity  is 
to  induce  contraction  of  the  muscles.  Either  the  f aradic  or  the  galvanic 
current  may  be  used.     The  f aradic  should  first  be  tried,  and  if  to  this 

*  Draper,  Peabody,  and  Dochez:  "Rockefeller  Institute  Reports,"  No.  iv. 

t  The  intraspinal  use  of  immune  human  serum  in  small  doses,  15  c.c,  combined 
with  its  use  subcutaneously  and  intravenously  may  prove  to  be  of  value  if  used 
very  early  in  the  attack. 


542  THE    PRACTICE    OF    PEDIATRICS 

there  is  no  response,  the  galvanic  should  be  used.  Sittings  of  five  to 
fifteen  minutes  may  be  desirable,  depending  somewhat  upon  the  age  of 
the  child  and  the  duration  and  extent  of  the  lesion.  The  longer  the 
duration  of  the  disease,  the  longer  should  be  the  sittings.  Once  daily 
the  parts  should  be  massaged  by  one  skilled  in  the  work.  When  such  a 
person  is  not  available,  the  mother  or  nurse  may  undertake  with  some 
advantage  the  systematic  manipulation  of  the  affected  muscles  by 
kneading  and  rubbing.  Gymnastic  exercises  are  unquestionably  of 
very  much  value,  but  must  be  carried  out  over  a  long  period  of  time. 
Cases  showing  niarked  atrophy  and  paralysis  and  which  promise  little, 
often  show  surprising  improvement,  and  restoration  of  function  under 
properly  directed  exercises  and  manipulative  treatment.  The  further 
management  is  orthopedic,  and  consists  in  the  prevention  of  deformi- 
ties by  the  use  of  splints  and  braces,  and  their  correction  by  teno- 
tomies and  tendon  transplantation. 

MULTIPLE  NEURITIS 

Multiple  neuritis  or  polyneuritis  is  an  acute  inflammatory  disease 
of  the  peripheral  nerves,  degenerative  in  character,  and  usually  sym- 
metric in  distribution. 

Etiology. — While  the  great  majority  of  cases  observed  in  children 
follow  diphtheria,  this  disease  is  by  no  means  the  only  causative  factor. 
The  neuritis  may  be  due  to  various  toxic  agents,  bacterial  and  other- 
wise, producing  an  inflammation  and  degeneration  of  the  peripheral 
nerves.  Among  the  possible  causes,  other  than  diphtheria,  are 
malaria,  the  exanthemata,  grip,  pneumonia,  erysipelas,  and  typhoid 
fever.  The  toxins  of  the  organism  causing  the  disease  are  responsible 
for  the  nerve  lesions  far  more  often  than  is  the  organism  itself.  Lead, 
phosphorus,  arsenic,  and  alcohol  as  possible  causes  are  to  be  kept  in. 
mind.  Lead  in  children  is  a  very  unusual  cause.  Arsenic,  phosphorus- 
and  alcohol,  however,  are  drugs  used  extensively  during  child  life  and 
should  always  be  considered  as  possible  etiologic  factors.  Instances- 
will  be  found  in  pediatric  literature  in  which  all  these  substances  have 
been  the  means  of  causing  multiple  neuritis.  I  recently  saw  two  pro- 
nounced cases  in  two  brothers  following  very  severe  scarlet  fever. 
Many  mild  cases  of  neuritis  in  children,  following  exhaustive  diseases' 
with  prolonged  toxemia,  are  doubtless  overlooked,  the  prolonged  time 
required  for  the  return  of  muscle  power  in  the  arms  and  legs  after 
disease  being  attributed  solely  to  muscle  weakness. 

Diphtheria. — Every  child  with  diphtheria  should  be  watched  and 
treated  as  if  diphtheric  paralysis  were  expected.  It  has  occurred  to 
some  extent  in  9  per  cent,  of  my  cases. 

In  paralysis  following  diphtheria  the  muscles  of  deglutition  take 
precedence.  There  may  be  paralysis  of  the  pharynx  and  larynx.  In- 
frequently, the  muscles  of  the  extremities  are  affected.  It  is  my  ex- 
perience that  if  the  heart  is  to  be  attacked,  signs  indicating  heart 
weakness  will  appear  early — soon  after  the  paralysis  of  other  parts  is 
apparent,  or  perhaps  as  an  earlier  symptom.     The  first  warning  is  the 


MULTIPLE    NEURITIS  543 

heart's  irregularity,  and  this  may  be  the  only  evidence  of  its 
involvement. 

Pathology. — The  nerves  affected  may  show  both  interstitial  and 
parenchymatous  changes.  Early  in  the  disease  there  is  a  congestion 
of  the  nerve-sheaths,  and  multiple  hemorrhages  have  been  found  in 
them.  Later  in  the  disease  the  nerves  undergo  the  changes  peculiar 
to  degeneration  in  nerve  structures. 

Distribution  of  the  Lesion. — A  peculiarity  of  the  lesion  is  that  the 
further  away  the  peripheral  nerve  structure  is  from  the  parent  cell,  the 
greater  is  the  susceptibility  of  the  nerve  to  the  influence  of  the  toxic 
agent.  The  anterior  tibial  group,  the  soft  palate,  and  the  muscles  of 
deglutition  are  most  frequently  involved. 

Sensory  Effects. — Sensory  disturbances  in  children  are  not  such 
prominent  symptoms  as  the  neurologist  would  have  us  believe,  for  the 
reason,  possibly,  that  he  usually  sees  only  the  more  severe  cases.  The 
mild  cases  seldom  come  under  his  care.  I  have  seen  quite  a  number  of 
the  mild  cases  in  which  there  were  sensory  disturbances  and  a  dimin- 
ished patellar  reflex  follo:wing  lobar  pneumonia  with  high  tempera- 
ture, and  also  after  severe  scarlet  fever. 

Symptoms. — The  symptoms  are  variable,  depending  upon  the 
parts  particularly  involved.  If  the  extremities  or  the  neck  muscles  are 
affected,  a  careful  observer  will  notice  a  gradual  loss  of  power.  The 
head  is  held  erect  with  difficulty.  The  child  is  timid  and  refuses  to 
walk.  Usually  there  are  a  few  falls  which  occasion  the  timidity.  The 
child,  if  old  enough,  complains  of  weakness  in  the  legs.  In  some  cases 
there  is  nothing  more  than  a  limp  to  indicate  the  disease.  Pain  may 
be  present,  but  has  been  of  unusual  occurrence  in  my  cases.  The  re- 
flexes may  be  diminished  or  absent.  The  characteristic  foot-drop  and 
wrist-drop  are  present  in  severe  cases. 

Cases  following  diphtheria  are  particularly  prone  to  paralysis  of  the 
muscles  of  deglutition.  The  child  attempts  to  swallow,  and  the  food 
returns  through  the  nose.  Deglutition  may  be  interfered  with  to  the 
point  of  impossibility  of  swallowing.  I  have  seen  several  of  these 
cases.  The  child  may  not  be  able  to  walk  or  sit  upright,  or  even  to 
support  the  head.  The  indication  of  heart  involvement  will  be  an 
irregularity  in  its  action.  Cases  in  which  the  heart  has  been  very  rapid 
or  very  slow  have  been  reported  by  other  observers.  In  my  cases  the 
heart  has  not  been  particularly  rapid,  neither  has  it  been  slow.  It  is 
irregular  in  that  for  ten  seconds  there  may  be  10  beats  and  during  the 
next  ten  seconds  perhaps  twice  this  number.  Pronounced  irregularity 
may  continue  for  two  or  three  weeks. 

Illustrative  Cases. — A  boy  six  years  of  age  had  a  very  mild  attack  of  diphtheria, 
not  of  sufficient  severity  (in  the  opinion  of  his  physician)  to  necessitate  liis  remain- 
ing in  bed.  Two  weeks  after  the  onset  of  the  attack,  at  which  period  he  came  under 
my  care,  there  was  marked  paralysis  of  the  soft  palate  and  pharynx  which  rendered 
swallowing  most  difficult.  In  spite  of  energetic  treatment  with  strychnin  hypo- 
dermatically,  the  paralysis  soon  involved  the  larynx,  the  masseters,  and  the  muscles 
of  all  the  extremities.  Fortunately  neither  the  heart  nor  the  diaphragm  was  in- 
volved. There  was  a  constant  flow  of  saliva,  which  at  times  entered  the  trachea 
unimpeded,  causing  severe  paroxysms  of  coughing.     In  order  to  prevent  this,  the 


544  THE    PRACTICE    OF    PEDIATRICS 

legs  and  trunk  were  elevated,  the  head  being  made  the  most  dependent  portion  of 
the  body.  Swallowing  was  impossible,  and  the  patient  was  given  by  gavage,  everj- 
six  hours,  completely  peptonized  milk,  whisky,  beaten  egg,  and  strychnin.  The 
boy  made  a  complete  recovery,  but  required  three  months  to  accomplish  it. 

In  the  case  of  another  patient,  fifteen  months  of  age,  gavage  was  practised  at 
six-hour  intervals  for  five  days  before  food  could  be  swallowed. 

Prognosis. — Complete  recovery  is  the  rule  if  there  is  no  cardiac  or 
respiratory  involvement,  although  several  weeks  or  months  may  be 
required  to  bring  about  complete  recovery. 

Few  cases  of  diphtheric  origin  recover  completely  under  eight  weeks. 

Cases  showing  only  a  slight  degree  of  heart  involvement  are  never 
free  from  danger. 

Illustrative  Case. — A  girl,  four  years,  apparently  well,  was  admitted  to  my  hos- 
pital service  with  post-diphtheric  paralysis  of  both  legs,  sufficient  to  prevent 
walking.  The  child,  while  resting  on  her  back,  dropped  a  top  to  the  floor.  She 
turned  over  and  attempted  to  reach  to  the  floor  for  the  top  and  expired.  The 
heart  had  previously  shown  some  irregularity,  and  the  child  had  been  placed  under 
close  observation,  which  was  momentarily  withdrawn. 

Diagnosis. — The  diagnosis  is  readily  made  through  the  multiple 
symmetric  distribution  of  the  paralysis,  the  impairment  of  or  complete 
loss  of  function  without  impairment  of  sensation,  and  finally  the  dis- 
turbed respiration  and  cardiac  irregularity. 

Electric  Reaction. — The  electric  reactions  are  exceedingly  variable, 
depending  on  the  degree  of  degeneration  in  the  nerves  and  on  the  varia- 
tions in  this  process  during  the  progress  of  a  case.  Early  in  the  disease 
both  galvanic  and  faradic  irritability  may  be  increased.  Faradic  re- 
sponses then  diminish,  and  though  galvanic  excitability  is  usually  in- 
creased temporarily,  there  is  ultimately  a  more  or  less  complete  reaction 
of  degeneration.  Only  in  the  most  severe  cases,  however,  is  the  gal- 
vanic response  completely  lost. 

Treatment. — General  Measures. — The  management  is  largely  pal- 
liative, as  there  is  a  strong  tendency  to  spontaneous  recovery  in  four  to 
eight  weeks  from  the  onset.  In  cases  due  to  the  use  of  alcohol  or  some 
other  drug,  the  elimination  of  the  exciting  cause  will  usually  be  followed 
by  recovery.  In  those  cases  due  to  the  toxemia  of  preceding  disease, 
time  and  good  care  are  usually  all  that  will  be  required  to  effect  a  cure. 
If  pain  is  present,  the  best  means  of  relief  is  afforded  by  heat.  The 
affected  limb  may  be  bound  in  thick  layers  of  cotton-wool. 

Drugs. — Salicylate  of  soda  and  iodid  of  potash  are  not  to  be  given 
to  young  children.  They  produce  no  appreciable  effect,  except  possi- 
bly a  disturbance  of  digestion  and  a  lessening  of  the  appetite.  Should 
the  pain  be  sufficient  to  interfere  with  sleep,  bromid  of  soda  may  be 
given  in  doses  of  8  to  12  grains  for  a  child  of  five  to  ten  years  of  age. 
This  is  best  given  at  bedtime  and  should  be  repeated  but  once.  In 
using  hypnotics  for  children,  one  drug  should  not  be  continued  longer 
than  three  days. 

Codein  is  a  satisfactory  sedative  for  a  child  in  case  the  bromid  does 
not  suffice.  Between  the  fifth  and  tenth  years,  from  V{q  to  3-^  grain  of 
codein  may  be  given  at  bedtime  and  repeated  once  after  an  interval  of 
three  hours. 


MULTIPLE    NEURITIS  545 

As  a  tonic  for  a  patient  from  five  to  ten  years  of  age  I  know  of  no 
better  combination  of  drugs  than  the  following. 

I^     StrychniniB  sulphatis ■ gr.  M 

Extract!  ferri  pomati gr.  x 

Quininse  bisulphatis 3j 

M.  div.  et  ft.  capsuliB  no.  xxx. 

Sig. — One  after  each  meal. 

If  constipation  is  present  or  should  result  from  the  administration  of 
iron,  from  3=-^  to  3^^  grain  of  extract  of  cascara  may  be  added  to  each 
capsule.  The  capsules  are  to  be  given  for  ten  days,  followed  by  cod- 
liver  oil  for  five  days.  The  oil  should  be  given  after  meals.  At  the 
end  of  the  five  days  the  tonic  capsules  are  to  be  repeated,  and  in  due 
time  followed  again  by  the  oil.  This  method  may  be  followed  as  long 
as  is  thought  necessary. 

Convalescence. — The  patient  should  have  the  benefit  of  an  outdoor 
life  as  early  as  possible.  Electricity  has  not  been  necessary  in  my 
cases,  nor  has  the  use  of  orthopedic  appliances  been  required.  Mas- 
sage may  be  used  with  advantage  after  subsidence  of  the  acute 
symptoms.     It  should  be  given  by  one  skilled  in  the  work. 

Treatment  of  Multiple  Neuritis  after  Diphtheria. — Cases  following 
diphtheria  require  pa.rticular  mention,  because  of  the  danger  of  involve- 
ment of  the  heart,  muscles  of  deglutition,  and  of  respiration.  If,  after 
ten  days  from  the  onset  of  throat  paralysis  or  paralysis  elsewhere,  there 
is  no  evidence  of  cardiac  involvement,  it  will  probably  not  develop  later, 
although  this  is  by  no  means  certain. 

Rest. — Should  the  heart  become  involved,  as  shown  by  irregularity 
or  attacks  of  fainting  or  nausea,  absolute  rest  in  the  recumbent  position 
is  important..  The  patient  should  be  constantly  under  the  eye  of  an 
attendant  and  should  not  be  allowed  to  turn  over  in  bed  or  raise  his 
head  without  assistance. 

Medication. — A  hypodermic  syringe  loaded  with  3^foo  grain  of 
strychnin  should  be  in  readiness  throughout  the  entire  illness  and  well 
on  into  convalescence.  Camphor  in  the  dose  of  13^^  grains  in  capsule 
may  be  kept  at  the  bedside,  ready  for  hypodermic  use. 

In  these  cases  we  rarely  have  to  deal  with  children  under  eighteen 
months  of  age,*  so  that  in  the  consideration  of  doses  only  children  over 
one  year  of  age  will  be  referred  to.  To  a  child  from  one  to  two  years 
old,  j'^oo  grain  of  strychnin  may  be  given  at  three-hour  intervals;  from 
two  to  four  years  of  age,  from  /^oo  to  /-f  50  grain  at  three-hour  intervals. 
After  the  fourth  year,  ^-fso  to  3-^00  grain  may  be  given  at  three-hour 
intervals.  When  there  is  marked  rapidity  of  the  heart's  action,  with 
irregularity  and  restlessness  in  those  under  three  years  of  age,  from 
one  to  two  drops  of  tincture  of  strophanthus  may  be  given  with  1/5  to 
Mo  grain  of  codein,  and  repeated  at  two-hour  intervals.  After  this 
age,  one  and  one-half  to  three  drops  may  be  given  with  3^f  0  to  }^  grain 
of  codein  at  two-hour  intervals.  The  codein  is  to  be  discontinued  as 
soon  as  the  restlessness  ceases.     For  those  in  whom  there  is  simply 

*  My  youngest  patient  with  diphtheric  paralysis  was  fifteen  months  old. 
35 


546  THE    PRACTICE    OF    PEDIATRICS 

paralysis  of  the  muscles  of  deglutition  or  of  the  extremities,  small  doses 
of  strychnin  will  be  all  the  medication  required,  from  3^oo  to  J^^oo 
grain  three  times  daily  being  sufficient. 

Gavage. — Troublesome  features  in  the  management  of  cases  in  which 
there  is  marked  involvement  of  the  muscles  of  deglutition,  and  the 
palate,  pharynx,  and  larynx,  consist  in  the  difl&culty  in  feeding  the 
patient  and  in  the  danger  of  his  aspirating  food  and  mucus  as  a  result  of 
paralysis.  For  such  patients  gavage  (p.  790)  may  be  used  with  much 
benefit.  From  6  to  10  ounces  of  food  may  be  introduced  into  the 
stomach  at  four-  to  six-hour  intervals.  In  using  the  so-called  forced 
feedings,  it  is  well  to  give  as  large  feedings  at  one  time  as  possible,  as  the 
process  is  always  resisted  by  the  patient.  In  the  cases  in  which  the  as- 
piration of  fluids  and  mucus  into  the  larynx  is  a  troublesome  or  danger- 
ous feature,  the  trunk  should  be  elevated  and  the  head  lowered. 

FACIAL  PARALYSIS 

Paralysis  of  the  facial  nerve  is  not  of  infrequent  occurrence  in  the 
young.  It  may  result  from  forceps  pressure  at  birth  or  from  pressure 
exerted  by  the  bony  parts  of  the  pelvic  outlet.  In  later  infancy  or 
childhood  it  may  be  the  result  of  trauma  caused  by  operative  manipula- 
tions, it  may  be  of  rheumatic  origin,  it  may  be  due  to  cerebellar  disease, 
or  to  exposure  to  cold.  In  one  of  my  patients  the  paralysis  was  attri- 
buted to  sitting  by  an  open  window  in  a  railroad  car  on  a  cold  day. 
The  nerve,  in  its  outward  passage  through  the  Fallopian  canal,  may  be- 
come diseased  from  the  presence  of  a  purulent  otitis  media.  This  is 
probably  the  most  frequent  cause  of  facial  paralysis.  Facial  paralysis 
may  be  caused  by  poliomyelitis.  During  the  1916  epidemic  a  vast 
number  of  cases  showed  facial  paralysis — many  without  other  paralytic 
signs.     In  others  the  paralysis  was  associated  with  other  lesions. 

Prognosis. — The  prognosis  depends  largely  upon  the  cause  of  the 
paralysis.  Cases  due  to  exposure  to  cold,  and  rheumatism,  and  those 
in  the  newly  born  that  are  due  to  birth  trauma  usually  terminate  in 
recovery. 

Cases  resulting  from  section  of ,  or  other  injury  of  the  nerve,  through 
accident  at  operation,  likewise  almost  always  have  a  satisfactory  out- 
come. The  unfavorable  cases  are  those  due  to  brain  disease,  such  as 
meningitis  or  tumor,  or  to  severe  injury,  such  as  fracture  or  caries  of  the 
temporal  bone. 

Treatment. — The  management  depends  entirely  upon  the  cause  of 
the  paralysis.  If  the  condition  is  due  to  cerebral  disease,  but  little  is 
to  be  expected  from  treatment.  If  it  is  due  to  an  otitis  media,  sur- 
gical procedures,  such  as  establishing  a  free  drainage  from  the  cavity  of 
the  middle  ear,  followed  by  frequent  hot  irrigations,  should  be  employed. 
If  these  are  ineffective,  the  mastoid  should  be  opened  and  the 
cavity  drained  posteriorly.  When  the  functional  activity  of  the  nerve 
is  delayed,  electricity  may  be  brought  into  use  in  the  manner  indicated 
below.  Cases  in  which  rheumatism  is  supposed  to  be  a  factor  should 
be  given  the  benefit  of  antirheumatic  treatment  by  the  use  of  the 


erb's  palsy  (obstetric  paralysis)  '547 

salicylates  (p.  711).     In  the  cases  due  to  cold  or  trauma  there  is  a 
strong  tendency  toward  recovery  without  treatment. 

It  is  difficult  to  judge  of  the  value  of  such  a  therapeutic  measure  as 
electricity;  but  the  effect  of  exercising  the  paralyzed  muscles  and 
stimulating  nerve  conduction  by  its  use  must  be  of  some  service.  If  the 
electricity  is  used,  five-minute  daily  sittings  are  all  that  are  necessary. 
The  faradic  current  should  be  employed  if  it  produces  sufficient  re- 
action; if  not,  the  interrupted  galvanic  current. 

ERB'S  PALSY  (OBSTETRIC  PARALYSIS) 

This  disease  is  due  to  a  traumatic  neuritis  caused  by  an  injury  of  the 
brachial  plexus  during  labor. 

Lesion. — The  injury  may  be  very  slight,  causing  but  a  temporary 
paralysis,  or  very  extensive,  causing  subsequent  degeneration  of  the 
nerve  structure.  The  essential  lesion  in  Erb's  palsy  is  an  injury  of  the 
fifth  and  sixth  cervical  nerve-roots  near  their  junction  on  emergence 
from  the  spinal  cord.  This  injury  may  involve  rupture,  laceration,  or 
bruising  of  the  nerves,  and  occasionally  hemorrhage  between  the  fibers. 
In  typical  cases  the  seventh  and  eighth  cervical  nerves  are  not  injured, 
but  occasionally  these  also  may  be  damaged.  The  muscles  principally 
affected  by  the  paralysis  are  the  deltoid,  biceps,  brachialis  anticus, 
supinator  longus  and  supinator  brevis,  the  spinati,  and  coraco- 
brachialis.  The  pectorals,  latissimus  dorsi  and  triceps  may  be  par- 
tially affected. 

Diagnosis. — The  chief  point  in  the  diagnosis  is  that  one  arm  alone  is 
involved.  Cases  of  bilateral  involvement  are  extremely  rare.  In  dif- 
erentiating  this  form  of  paralysis  from  cerebral  palsies  it  will  be  noted 
that  there  is  a  flaccid  paralysis  with  some  degree  of  atrophy.  There  is 
never  spasticity,  and  the  mentality  is  normal.  After  a  few  months  the 
affected  limb  becomes  smaller  and  much  softer  than  the  unaffected  arm. 
Owing  to  the  location  of  the  muscles  involved  and  because  of  the  paraly- 
sis of  the  supinator  group,  the  arm  is  often  rotated  inward,  throwing  the 
palm  of  the  hand  outward  and  backward.  Owing  to  paralysis  of  the 
extensors,  due  to  involvement  of  the  musculospiral  nerve,  the  fingers 
and  thumb  are  in  a  more  or  less  permanent  condition  of  flexion-fixation. 

Prognosis. — In  the  main  the  prognosis  is  favorable,  but  not  as  fa- 
vorable, from  my  observation,  as  the  literature  would  lead  us  to  believe. 
In  fact,  a  guarded  prognosis  should  always  be  given.  I  have  seen  com- 
plete recoveries.  A  case  involving  fracture  of  the  humerus  with  com- 
plete paralysis  underwent  complete  recovery  in  three  months.  I  have 
seen  partial  recoveries  in  other  instances,  and  again  other  cases  in 
which  the  lesion  was  of  such  a  nature  as  to  make  recovery  impossible. 
We  may  safely  say  that  all  the  subjects  improve  and  that  they  may 
recover  entirely,  but  we  are  not  in  a  position  to  promise  any  outcome 
in  a  given  case.  Improvement  should  not  be  despaired  of  even  after 
several  months  have  elapsed.  I  have  known  cases  in  which  the  im- 
provement continued  to  the  eighth  and  tenth  year.  In  a  few  cases  the 
paralysis  and  deformity  are  permanent.     If  there  is  complete  paraly- 


548  THE    PRACTICE    OF    PEDIATRICS 

sis  after  one  year  it  may  safely  be  assumed  that  the  paralysis  will  be 
permanent. 

Sachs  states  that  even  in  the  event  of  complete  paralysis,  recovery 
msLj  be  looked  for  in  the  cases  showing  a  sHght  response  to  faradism, 
in  two  or  three  months.  When  there  is  no  faradic  response,  but  re- 
action to  the  galvanic  current,  the  restoration  of  power  may  be  expected 
in  six  months.  In  those  cases  in  which  there  is  no  galvanic  or  faradic 
response,  a  year  or  two  may  be  required  before  the  arm  is  normal. 

Treatment. — The  atrophy  and  contractions  which  develop  are 
determined  largely  by  the  extent  of  the  injury,  and  to  a  lesser  degree 
by  the  treatment.  During  the  first  three  weeks  in  lifting  and  handling 
the  infant  the  arm  should  be  protected  from  other  injuries,  such  as  may 
take  place  in  bathing  and  the  other  manipulation  necessary  in  the  care 
of  the  baby.  After  this  time  massage  of  the  entire  arm  and  shoulder 
with  lanolin  should  be  practised  at  least  twice  a  day,  from  ten  to  fifteen 
minutes  at  a  time.  After  two  weeks  electricity  may  be  used  for  a  few 
minutes  each  day.  If  the  child  can  bear  it,  the  faradic  current  answers 
best.  In  case,  however,  there  is  no  response  to  faradism,  the  galvanic 
current  should  be  used.  Under  massage  and  electricity  the  improve- 
ment in  the  arm  is  often  most  satisfactory.  It  is  not  well,  however,  to 
promise  the  parents  that  a  normal  arm  will  be  the  outcome.  I  have 
seen  cases  in  which  there  was  complete  restoration  of  power  after  it  had 
been  entirely  lost,  while  in  others  the  arm  was  permanently  disabled. 
The  degree  of  improvement  is  dependent  upon  several  factors,  the  chief 
one  of  which  (the  extent  of  the  nerve  injury)  is  in  every  case  uncertain. 

Operative  measures,  consisting  of  grafting  and  transplanting  of  the 
nerve,  have  recently  been  advocated  by  many  surgeons.  Sharpe*  of 
New  York  recommends  this  procedure  in  cases  with  complete  paralysis 
at  the  end  of  one  month. 

Such  a  degree  of  paralysis  means  that  there  has  been  an  extensive 
injury  and  tear  in  the  plexus.  In  such  an  instance  there  is  bound  to 
be  an  impaired  arm.  The  early  operation  is  advised  in  order  to  head 
off  the  formation  of  large  masses  of  fibrous  tissue.  The  earlier  the 
anastomosis  of  the  nerve  roots,  the  more  perfect  the  union  of  the  torn 
nerve  structures  and  consequently  a  better  ultimate  result. 

An  important  feature  in  the  management  of  these  cases  consists  in 
the  prevention  of  deformity  through  contractures.  This  may  be  ac- 
complished by  the  use  of  suitable  orthopedic  appliances. 

The  value  of  manipulation  treatment  and  electricity  is  difficult  to 
determine.  Dispensary  cases  in  which  no  treatment  of  moment  was 
carried  out  have  made  very  satisfactory  progress,  providing  contrac- 
tures and  deformities  were  not  allowed  to  develop. 

FRIEDREICH'S  ATAXIA  (HEREDITARY  ATAXIA) 

Friedreich  was  the  first  to  describe  this  affection  and  establish  a 
clinical  entity.     The  designation,  "hereditary  ataxia,"  is  faulty  for  the 
reason   that  heredity  does   not  necessarily  enter  into  consideration. 
*  Journal  A.  M.  A.,  March  18,  1916. 


Friedreich's  ataxia  (hereditary  ataxia)  549 

Two  brothers,  aged  four  and  six  years,  developed  the  disease;  the 
family  history  was  otherwise  perfect.  This  disease,  however,  shows 
a  tendency  to  family  selection,  Gowers  refers  to  65  cases  occurring  in 
19  families.  The  number  of  cases  in  one  family  was  as  high  as  10. 
Gowers  finds  the  sexes  about  equally  divided  as  regards  liability. 
Sachs,  in  a  wide  experience,  has  never  seen  a  case  in  a  girl. 

Pathology. — Neurologists  agree  that  the  pathology  of  Friedreich's 
disease  is  not  well  understood.  Sachs  states  that  "one  fact  is  indis- 
putable, in  microscopic  examinations  a  sclerosis  of  the  spinal  cord  is 
found  involving  at  different  levels  or  at  one  and  the  same  levels  various 
systems  of  the  cord.  The  sclerosis  affects  most  frequently  the  posterior 
columns  or  the  lateral  columns  or  both  together,  and  hence  the  symp- 
toms vary  between  those  of  a  pure  posterior  spinal  sclerosis  and  those 
due  to  a  posterior  lateral  sclerosis,  resembling  the  symptoms  of  the 
ataxic  paraplegia  of  the  adult." 

Symptoms. — Walking  is  early  interfered  with,  and  the  child  stands 
with  difficulty.  The  gait  is  peculiarly  ataxic.  The  feet  are  placed 
widely  apart,  and  the  patient's  attempts  at  locomotion  are  attended 
with  uncertainty  and  hesitancy.  Romberg's  symptom  was  present  in 
the  two  boys  referred  to.  Neurologists  tell  us  that  this  symptom  is 
variable. 

Incoordination  in  the  use  of  the  arms  is  present,  not  unlike  that  in 
chorea.  Attempts  at  a  concise  volitional  act  with  the  upper  extremi- 
ties— such  as  writing,  bringing  the  ends  of  the  index-fingers  together,  or 
placing  the  tips  of  the  fingers  on  the  tip  of  the  nose — result  in  hesitancy, 
tremor,  and  imperfection  in  the  act  attempted.  In  fact,  the  act  can  be 
accomplished  only  with  much  effort  and  after  several  attempts,  if  at  all. 

Sensation  is  not  greatly  interfered  with. 

As  the  disease  progresses  choreic  movements  of  the  head  and  face 
develop.  The  Babinski  reflex  is  usually  present.  The  patellar  reflex 
is  lost.     There  is  gradual  loss  of  muscle  power  and  later  emaciation. 

The  patient  is  mentally  slow  and  diffident.  There  is  an  entire  loss 
of  confidence,  and  this  is  stamped  on  the  countenance  and  is  manifested 
in  every  voluntary  act.  The  child  hesitates  and  speaks  slowly,  as 
though  ideas  were  hard  to  formulate  into  words. 

The  eye  changes  are  not  important.  Nerve  atrophy  does  not  occur, 
and  the  Argyll  Robertson  pupil  is  absent. 

Prognosis. — The  disease  is  slowly  progressive  and  fatal,  although 
several  years  may  be  required  before  the  fatal  termination,  which  is 
usually  the  result  of  intercurrent  disease.  The  duration  of  the  ataxia 
is  rarely  longer  than  ten  years.  The  patient  may  succumb  before  the 
fifth  year. 

Differential  Diagnosis. — True  tabes  may  be  differentiated  from 
Friedreich's  ataxia  by  the  absence  of  mental  impairment  and  spinal 
defects,  both  of  which  conditions  belong  to  Friedreich's  disease.  The 
Argyll  Robertson  pupil  is  present  in  tabes  and  absent  in  Friedreich's 
ataxia.  Choreic  movements  of  the  upper  extremities  are  the  rule  in 
Friedreich's  disease  and  absent  usually  in  tabes. 


550  THE    PRACTICE    OF    PEDIATRICS 

Treatment. — No  known  form  of  medication  is  of  value.  All  that 
may  be  accomplished  in  the  treatment  relates  to  the  comfort  of  the 
patient. 

ACUTE  INFECTIVE  MENINGITIS 

Acute  meningitis,  as  its  name  implies,  is  an  acute  inflammation  of 
the  meninges  covering  the  brain  and  cord. 

Etiology. — -Acute  meningitis  may  be  either  a  primary  or  a  secondary 
disease.  The  miore  common  sources  of  acute  meningitis  are  suppura- 
tion in  the  ears,  nose,  and  eyes,  head  injuries,  and  systemic  infections 
with  a  bacteremia  such  as  typhoid,  influenza,  pneumonia,  and  infective 
endocarditis. 

When  primary,  meningitis  is  usually  due  to  the  meningoccus  or  the 
pneumococcus. 

Cases  of  secondary  origin  are  usually  the  result  of  the  invasion  of 
the  staphylococcus.  The  streptococcus,  colon  bacillus,  typhoid  and 
influenza  bacillus  may  also  be  included  in  the  latter  group,  the 
cerebral  involvement  following  pneumonia,  or  an  intestinal  infection 
or  typhoid  fever.  Streptococcus  or  staphylococcus  meningitis  is  often 
a  complication  of  middle  ear,  mastoid,  or  sinus  disease. 

Pathology. — The  changes  occurring  locally  in  and  about  the  brain 
depend  on  the  character  and  source  of  the  infection.  In  ear  infections 
the  lesions  are  often  unilateral  and  accompanied  by  a  sinus  thrombosis. 
In  the  majority  of  the  other  cases  the  vessels  of  the  pia  are  congested  and 
give  origin  to  small  hemorrhages,  and  the  surface  of  the  brain  is  covered 
with  seropurulent  or  fibrinopurulent  exudate;  the  convolutions  are 
flattened  to  a  degree  depending  on  the  amount  of  associated  hydro- 
cephalus. Accompanying  cord-involvement  is  the  rule.  The  presence 
of  a  large  amount  of  greenish-yellow  exudate  over  the  anterior  portion 
of  the  cerebral  cortex,  with  many  fibrinous  adhesions,  is  very  character- 
istic of  pneumococcus  meningitis.  In  certain  infective  fevers,  such  as 
measles  and  scarlet  fever,  acute  serous  meningitis  may  occur. 

In  a  private  case  due  to  the  pneumococcus  the  anterior  half  of  the 
brain  cortex  (see  Plate  I)  was  incased  in  pus. 

Symptoms. — If  the  case  is  primary  and  due  to  the  pneumococcus, 
the  onset  may  be  sudden,  with  vomiting  and  convulsions,  both  of  which 
may  be  repeated  many  times.  With  the  active  manifestations  there 
will  be  at  first  drowsiness,  followed  by  stupor  from  which  the  child  can 
with  difficulty  be  aroused.  Usually  the  active  symptoms,  such  as 
vomiting  and  convulsions,  are  absent  in  the  secondary  cases. 

The  first  indication  of  cerebral  involvement  will  be  drowsiness, 
stupor,  irregular  respiration,  and  irregular  pulse.  A  disturbance  of  the 
heart  action  is  a  very  significant  and  early  sign.  It  may  be  irregular, 
intermittent,  or  it  may  be  very  rapid  and  regular.  I  have  repeatedly 
seen  the  heart  action  at  140  to  180  a  minute,  with  practically  a  normal 
temperature.  Vasomotor  disturbance  indicated  by  the  tache  cere- 
brale  may  be  an  early  symptom.  A  tense  fontanel  is  rarely  absent,  and 
is  one  of  our  most  valuable  signs.     The  pupils  are  usually  dilated  sym- 


PLATE  1 


'A[^ 


Pneumococcus  meningitis. 


ACUTE    INFECTIVE    MENINGITIS  551 

metrically  or  unevenly,  and  show  little  or  no  response  to  light.  Hyper- 
esthesia and  rigidity  of  the  neck  may  be  present. 

Purposeless  movements  of  the  leg  or  arm  are  often  seen  when  the 
symptoms  of  the  disease  are  well  marked.  The  leg  or  arm  is  raised  and 
allowed  to  fall;  this  is  repeated  for  hours  at  a  time.  An  elevation  of 
temperature  is  usually  present.  It  may  be  high,  low,  or  variable. 
Swallowing  is  early  interfered  with. 

In  the  patient  above  referred  to,  whose  brain  is  shown  in  Plate  I, 
the  first  sign  was  a  temperature  of  102°F.,  a  greatly  distended  fontanel, 
and  stupor.     The  child  died  in  three  days,  aged  seven  months. 

Diagnosis. — There  is  no  characteristic  temperature  range.  The 
only  positive  information  as  to  the  nature  of  the  infection  is  obtained 
by  lumbar  puncture ;  only  in  this  way  can  a  positive  differential  diag- 
nosis between  acute  simple,  tuberculous,  and  cerebrospinal  meningitis 
be  made. 

In  many  severe  diseases  in  which  there  is  marked  toxemia,  symp- 
toms closely  resembling  meningitis  will  be  in  evidence.  In  pneu- 
monia, in  the  severe  intestinal  infections,  and  in  heat  prostration  the 
cerebral  symptoms  so  closely  simulate  those  of  meningitis  that  a  posi- 
tive diagnosis  without  lumbar  puncture  may  be  impossible.  Before 
the  advent  of  lumbar  puncture  I  have  seen  most  excellent  clinicians 
diagnose  meningitis  in  cases  which  at  autopsy  showed  no  pathologic 
condition  in  the  brain.  I  have  further  known  cases  so  diagnosed  to 
recover  too  promptly  to  be  a  comfort  to  the  attending  physician. 

Differential  Diagnosis. — Acute  simple  meningitis,  tuberculous 
meningitis,  cerebro-spinal  meningitis,  anterior  poliomyelitis  and  men- 
ingismus  may  all  show  certain  symptoms  in  common,  sufficient  to  re- 
quire a  lumbar  puncture  with  examination  of  the  spinal  fluid,  cultural 
and  otherwise,  in  order  that  a  positive  diagnosis  be  made.  In  acute 
simple  meningitis  the  fluid  is  usually  turbid,  and  when  allowed  to 
stand,  a  considerable  deposit  of  pus  forms  in  the  tube,  bacteriological 
examination  of  which  determines  the  nature  of  the  infection.  The 
cells  present  in  the  fluid  are  almost  exclusively  polymorphonuclear 
leucocytes.  In  meningismus  there  are  the  signs  of  drowsiness,  stupor, 
and  perhaps  hyperesthesia  and  immobility  of  the  pupils,  but  no  irregu- 
larity of  the  pupils  and  rarely  irregular  respiration  and  distention  of 
the  fontanel.  Particularly  significant  in  such  cases  is  the  absence  of 
signs  of  irregularity  or  slowness  in  the  heart  action.  Acute  simple 
meningitis  may  closely  resemble  that  due  to  the  meningococcus 
(cerebrospinal),  particularly  if  the  influenza  bacillus  or  the  pneumococ- 
cus  is  the  infecting  agent. 

Prognosis. — The  prognosis  is  most  unfavorable.  I  have  yet  to  see 
recovery  in  a  case  in  which  the  diagnosis  was  proved  by  lumbar  punc- 
ture.    Occasionally  such  recoveries  are  reported. 

Treatment. — The  most  one  can  do  in  acute  simple  meningitis  is  to 
nourish  the  patient  and  lessen  his  discomfort.  We  have  no  means  of 
treatment  that  may  be  considered  in  any  sense  curative.  By  the  use 
of  repeated  lumbar  puncture  we  can  in  some  cases  make  the  patient 


552  THE    PRACTICE    OF    PEDIATRICS 

more  comfortable,  and  perhaps  aid  him  to  resist  the  infection.  The 
pulse  and  the  respiration  improve,  as  well  as  the  urgency  of  the  nervous 
phenomena;  the  opisthotonos  and  the  excessive  hyperesthesia  may  be 
temporarily  relieved.  There  is  no  rational  ground,  however,  for  ex- 
pecting the  withdrawal  of  the  cerebrospinal  fluid  to  be  curative;  nor 
may  the  injection  of  disinfectant  drugs  into  the  canal  be  expected  to 
aid  in  controlling  the  disease. 

Lumbar  Puncture. — Lumbar  puncture  (p.  566)  may  be  practised  as 
frequently  as  once  in  twenty-four  hours,  the  frequency  of  such  proce- 
dure depending,  of  course,  upon  the  condition  of  the  patient  and  the 
relief  afforded.  The  use  of  lumbar  puncture  more  frequently  than 
once  in  twenty-four  hours,  as  has  been  suggested  by  some  writers,  is 
not,  however,  to  be  advised.  The  amount  of  fluid  to  be  withdrawn 
depends  upon  the  pressure  in  the  canal  as  indicated  by  the  passage  of 
fluid  through  the  cannula,  from  one  to  three  ounces  being  the  usual 
amount  withdrawn.  Strict  surgical  precautions  as  regards  asepsis 
should  be  observed  in  performing  the  operation.  One  dram  of  aristol 
in  one  ounce  of  collodion,  applied  with  a  camel's-hair  brush,  makes 
a  suitable  protective  dressing  after  the  withdrawal  of  the  cannula. 

Warm  Packs. — The  vv^arm  pack  or  warm  bath  at  105°F.,  by  lessen- 
ing the  cerebral  blood-pressure,  may  also  assist  in  relieving  the  more 
active  nervous  manifestations.  If  the  bath  is  used,  the  child  should 
not  be  kept  in  it  longer  than  three  minutes.  I  usually  prefer  the  hot 
pack.  A  large  bath-towel  or  medium-weight  flannel  sheet  is  wrung  out 
of  water  at  110°F.  and  wrapped  around  the  child's  body  from  the 
waist  down.  This  is  repeated  at  half-hour  intervals  for  three  hours, 
when,  after  a  period  of  rest  for  an  hour  or  two,  the  packs  may  be  re- 
sumed. 

Diet. — The  proper  nutrition  of  the  patient  with  meningitis  is  often 
a  matter  of  no  little  difficulty.  The  child  may  either  refuse  the  food,  or 
be  unable  to  swallow.  Nutrition  by  means  of  the  rectum  or  colon  may 
be  of  assistance  for  a  few  days,  but  cannot  be  rehed  upon  for  long 
periods  for  the  reason  that  the  parts  become  intolerant  and  the  nutrient 
enemata  are  expelled.  Feeding  by  means  of  gavage  is  always  to  be 
employed  when  other  means  fail.  The  younger  the  child,  the  more 
applicable  this  method.  The  feeding  should  not  be  attempted  oftener 
than  at  four-hour  intervals;  usually,  feeding  every  six  hours  suflices. 
Completely  peptonized  full  milk  (p.  69)  is  usually  given  in  quantities 
suitable  for  the  age.  After  a  few  trials  of  gavage  the  patient  may  take 
the  nourishment  by  the  usual  method,  or  the  gavage  may  be  kept  up 
indefinitely. 

Sedatives. — Sedatives  may  be  employed  with  a  view  to  saving  the 
strength  of  the  patient.  Morphin,  codein,  the  bromid  of  soda,  or 
chloral  may  be  given.  As  morphin  and  codein  increase  the  usual 
existing  constipation,  their  use  should  be  very  temporary.  The 
bromid  of  soda  for  the  cases  which  may  require  the  protracted  ad- 
ministration of  a  sedative  answers  better  than  any  other  form  of  medi- 
cation.    To  an  infant  under  eighteen  months  of  age,  from  2  to  4  grains 


TUBERCULOUS    MENINGITIS  553 

may  be  given  at  intervals  of  two  to  three  hours,  according  to  the  results. 
In  case  the  nervous  symptoms  are  very  urgent,  3^^  to  1  grain  of  chloral 
may  be  added.  Should  administration  by  mouth  be  impracticable,  the 
sedative  may  be  given  by  rectum,  by  means  of  a  rectal  tube  inserted 
at  least  9  inches.  In  using  the  bromid  and  chloral  in  this  way  twice 
the  amount  of  chloral  and  thrice  the  amount  of  bromid  employed 
in  stomach  administration  should  be  given.  After  the  eighteenth 
month,  from  1  to  2  grains  of  chloral  and  from  4  to  8  grains  of  the  bromid 
well  diluted  may  be  given  by  the  stomach,  and  repeated  as  often  as  may 
be  necessary.  In  case  the  medication  is  to  be  given  by  rectum,  it 
should  be  diluted  with  at  least  4  ounces  of  water,  and  proportionately 
more  given,  as  suggested  for  younger  children. 

TUBERCULOUS  MENINGITIS 

Tuberculous  meningitis  is  one  of  the  most  fatal  diseases  of  childhood. 
As  its  name  implies,  it  is  a  tuberculous  inflammation  of  the  meninges. 
The  frequency  of  the  disease  is  due  to  the  favorable  field  offered  by  the 
covering  of  the  brain  for  bacterial  growth  and  the  wide  dissemination  of 
the  tubercle  bacillus.  The  rapid  development  of  the  brain,  the  birth 
weight  of  which  is  increased  about  four  times,  during  the  first  four 
years  of  life,  necessitates  rapid  development  and  active  work  on  the 
part  of  the  blood-vessels,  and  lymphatics.  These,  therefore,  supply  a 
favorable  culture  field  for  the  invading  organism. 

Age. — No  age  is  exempt.  My  youngest  patient  was  three  months 
old.  Between  the  first  and  third  year  the  greatest  number  of  cases 
occur.  The  disease  is  rare  after  the  eighth  year.  I  have  seen  four 
cases  between  the  twelfth  and  the  eighteenth  year. 

Pathology. — This  form  of  meningitis  is  usually  secondary  to  tuber- 
culosis elsewhere  in  the  body,  and  is  very  usually  part  of  a  general 
miliary  infection.  Out  of  413  fatal  cases  of  tuberculosis  in  children, 
Shennan  reports  tuberculous  meningitis  in  184,  or  44.5  per  cent.  In 
77  of  these  cases  the  disease  had  spread  from  mediastinal  glands;  in  26, 
from  abdominal  glands;  and  in  a  small  number,  from  an  active  pul- 
monary inflammation.  Transmission  is  practically  always  through 
the  blood.  Miliary  tubercles  may  be  numerous  on  the  walls  of  the 
blood-vessels  of  the  pia  mater,  over  all  surfaces  of  the  cerebrum, 
cerebellum  and  cord,  but  they  are  usually  most  numerous  at  the  base, 
between  the  peduncles.  There  may  be  more  or  less  exudate  of  fibrin 
and  leukocytes  at  the  base.  The  spinal  fluid  is  increased  in  amount 
and,  owing  to  the  closure  of  the  foramen  of  Magendie  by  inflammatory 
exudate,  the  lateral  ventricles  become  dilated.  The  ependyma  may 
contain  many  miliary  tubercles.  Flattening  of  the  cerebral  convolu- 
tions may  result  from  accumulation  of  fluid  in  the  ventricles. 

Symptomatology.— Tuberculous  meningitis  is  variable  in  its  early 
manifestations.  Probably  one  of  the  earliest  indications  of  the  disease 
is  a  change  in  the  disposition  of  the  patient.  A  happy,  easily  pleased 
child  becomes  cross  and  disagreeable,  and  may  remain  for  days  in  this 


554  THE    PRACTICE    OF    PEDIATRICS 

condition.     In  getting  the  history  of  a  case  I  have  repeatedly  heard 
these  symptoms  brought  forward. 

Illustrative  Cases.— A  girl  patient,  three  years  of  age,  was  in  the  habit  of  going 
to  the  park  daily.  On  her  return  home,  regardless  of  the  street  selected  by  the 
nurse,  the  child  insisted  on  turning  back  and  passing  through  another  street. 
The  child  was  very  irritable  and  refused  to  play  with  other  children.  The  mother 
had  been  in  the  habit  of  singing  several  songs  to  the  child.  The  child  selected  one 
and  would  Jiave  no  other.  She  was  not  content  out  of  the  mother's  arms,  and 
insisted  that  the  song  constantly  be  sung  to  her  while  awake.  The  mother  became 
nearly  distracted  at  the  constant  performances,  and  at  this  time,  after  three  weeks 
of  decided  mental  aberration  on  the  part  of  the  child,  brought  her  under  my  care. 
The  child  died  five  weeks  later  from  tuberculous  meningitis. 

Two  cases  have  recently  come  under  my  observation  in  which  the  first  symptom 
and  the  only  symptom  for  two  weeks  was  intense  headache. 

There  may  be  vomiting  without  apparent  cause,  and  if  the  vomit- 
ing is  repeated  one  or  more  times  on  successive  days  and  associated  with 
other  suggestive  signs,  it  constitutes  a  symptom  of  no  Httle  value. 

Convulsions  may  usher  in  the  disease.  The  convulsions  are  apt  to 
be  repeated  several  times. 

Mental  disturbance,  vomiting  without  apparent  cause,  convulsions, 
loss  of  appetite,  constipation,  restlessness  at  night,  and  night-cries 
belong  to  the  earlier  manifestations.  After  a  week  or  perhaps  two  weeks 
of  pronounced  though  indefinite  signs  the  child  becomes  dull  and 
apathetic,  sleeps  a  great  deal,  and  rapidly  passes  into  a  condition  of 
semi-stupor  from  which  he  is  aroused  with  difficulty.  Hyperesthesia 
and  exaggerated  reflexes  may  be  present  early  in  the  disease.  With 
the  progress  of  the  case  they  often  disappear.  The  fontanel  early  be- 
comes tense  and  bulging — a  very  valuable  sign. 

Decided  evidences  of  cerebral  pressure  now  ma,ke  their  appearance. 
The  respiration  becomes  irregular.  The  pulse-rate  is  60  to  80  instead 
of  100  to  120.  At  times  the  pulse  will  change  very  markedly  and  be- 
come rapid  for  a  few  hours;  as  a  rule,  it  is  characterized  by  slowness 
and  irregularity.  Rigidity  of  the  neck,  slight  opisthotonos,  and  spas- 
ticity of  the  extremities  appear.  During  this  time  the  child  will  usu- 
ally swallow  if  food  is  given.  In  many  cases  there  is  an  incoordinate, 
almost  perpetual  motion  of  the  arm  and  leg  on  one  side  of  the  body. 
The  pupils  become  sluggish,  responding  slowly  to  light  stimulation, 
or  fail  to  show  any  response.  The  pupils  may  be  unequal.  One  pupil 
may  respond  to  light  while  the  other  remains  stationary. 

There  is  no  characteristic  temperature  in  tuberculous  meningitis. 
The  usual  range  is  between  99°  and  102°F.     It  may  be  higher  or  lower. 

Very  few  cases  of  uncomplicated  tuberculous  meningitis  occur,  as 
mentioned  before.  The  meningitis  is  usually  associated  with  tuber- 
culous processes  elsewhere,  which  exert  a  controlling  influence  on  the 
temperature. 

Later  Symptoms. — The  coma  increases.  It  is  impossible  to  arouse 
the  child.  Liquid  food  placed  in  the  mouth  remains  there  or  runs  out 
at  the  sides.  The  breathing  is  labored.  Cheyne-Stokes  respiration 
develops.  The  pulse  becomes  slower  and  intermittent  and  irregular 
and  the  child  dies. 


TUBERCULOUS    MENINGITIS  555 

Regardless  of  the  age,  the  signs  and  symptoms  are  very  similar. 

Occasionally  one  meets  with  fulminating  cases  with  sudden  onset 
with  urgent  symptoms  of  vomiting,  high  fever,  rapidly  developing  stu- 
por, and  irregular  pulse  and  respiration.  Such  cases  are  rare,  and 
when  they  occur,  are  easily  confused  with  those  of  cerebrospinal 
meningitis. 

Diagnosis. — Early  positive  diagnosis  is  impossible  unless  the  case 
is  a  very  active  one.  With  the  development  of  pressure  signs,  certain 
phenomena  appear  which  point  very  strongly  to  the  nature  of  the 
disease. 

Rigidity  of  the  neck  is  usually  present  in  some  degree.  When  the 
child 's  head  is  raised  from  the  pillow,  the  entire  body  may  be  elevated 
accordingly. 

Fulness  of  the  fontanel  (in  case  the  fontanel  has  not  become  closed) 
is  always  present  in  greater  or  less  degree,  and  is  a  sign  of  much  value. 

Slow,  irregular  pulse,  and  slow,  uneven  respiration  are  symptoms  of 
great  diagnostic  value.  Rarely  does  a  case  pass  through  its  various 
phases  without  showing  these  phenomena. 

Drowsiness,  gradually  increasing,  followed  by  stupor  and  coma,  is  a 
constant  manifestation. 

Unequal,  inactive,  usually  dilated  pupils  will  be  found  in  cases  well 
advanced. 

Repeated  vomiting  without  apparent  cause,  in  the  presence  of  sug- 
gestive signs,  supplies  valuable  corroborative  evidence. 

The  Kernig  sign  consists  of  an  inability  to  extend  the  leg  on  the  thigh 
when  the  thigh  is  flexed  on  the  abdomen.  This  symptom  is  present  in 
nearly  all  cases  late  in  the  disease. 

The  Babinski  reflex  and  Oppenheim's  reflex,  about  which  much  is 
written,  are  of  very  little  value;  if  present,  they  corroborate  other 
findings.  Their  absence  means  nothing.  True,  they  may  be  present 
in  a  certain  proportion  of  cases  of  tuberculous  meningitis,  but  they  are 
present  in  tetany  and  so-called  tetanoid  states  from  whatever  cause, 
and  they  may  also  be  present  in  brain  injury  and  in  spastic  paraplegia 
due  to  birth  trauma. 

The  -temperature  range  is  of  no  value  in  diagnosis  for  reasons 
already  given.  Optic  neuritis  is  present  in  a  majority  of  the  cases 
late  in  the  disease.  Tubercles  in  the  choroid  will  be  found  in  most 
cases. 

Lumbar  Puncture. — A  positive  diagnosis  can  be  made  only  by 
lumbar  puncture  (p.  566) .  Tubercle  bacilli  would  be  found  in  the  spinal 
fluid  in  practically  all  cases  of  tuberculous  meningitis,  although  it  may 
be  necessary  to  make  more  than  one  examination.  In  withdrawing 
the  fluid,  that  which  is  drawn  last  should  be  collected  for  the  examina- 
tion. The  test-tube,  in  which  10  to  15  c.  c.  of  fluid  has  been  drawn, 
should  then  be  allowed  to  rest  at  room-temperature  for  twelve  to 
eighteen  hours,  when  a  delicate  clot  of  fibrin  will  have  formed  in  the 
fluid.  The  fluid  is  not  to  be  agitated.  The  fibrin  may  then  be 
removed  and  examined  by  the  usual  methods  for  the  detection  of 


556  THE  PRACTICE  OF  PEDIATRICS 

tubercle  bacilli.  The  spinal  fluid  shows  lymphocytosis  and  the  globulin 
test  is  positive. 

In  one  case  occurring  under  my  care  the  tubercle  bacilli  were  not 
found  until  the  tenth  examination  was  made.  The  child  had  all  the 
usual  symptoms  of  meningitis,  and  there  were  tubercle  bacilli  in  the 
bronchial  secretion;   the  examinations   were,   therefore,  persisted  in. 

The  appearance  of  the  fluid  withdrawn  is  suggestive,  being  bright 
and  clear  or  slightly  opalescent  in  tuberculous  meningitis,  while  in 
other  forms  it  is  usuallj^  turbid  and  cloudy.  The  globulin  and  cellular 
content  of  the  fluid  are  both  increased  and  the  leukocytes  present 
are  90  per  cent,  mononuclear. 

Differential  Diagnosis. — The  first  problem  in  a  given  case  is  to  de- 
cide whether  there  is  a  meningitis  and  whether  the  signs  are  such  as 
to  warrant  further  investigation.  Such  being  the  case,  a  differentiation 
as  to  the  type  we  are  dealing  with  is  necessary,  and  here  again  lumbar 
puncture  must  be  brought  into  use.  While  we  may,  with  a  consider- 
able degree  of  accuracy,  judge  as  to  the  nature  of  the  infection,  cases  are 
frequently  encountered  in  which  a  differentiation  is  impossible  without 
lumbar  puncture. 

We  may  have  a  very  active  condition  due  to  the  tubercle  bacillus 
which  may  be  readily  confused  clinically  with  meningitis  of  the  cere- 
brospinal type.  Again,  I  have  seen  several  proved  cases  of  mild  cere- 
brospinal meningitis  which  surely  would  have  been  diagnosed  as  tu- 
berculous without  the  proof  supplied  by  the  lumbar  puncture.  In 
tuberculous  meningitis  the  Von  Pirquet  test  is  always  positive. 

The  most  frequent  error  made  is  in  the  cases  of  grave  systemic 
poisoning  with  active  cerebral  manifestations.  In  pneumonia,  scarlet 
fever,  heat  prostration,  and  in  the  acute  intestinal  infections,  the 
stupor,  the  convulsions,  and  vomiting  often  are  interpreted  as  due  to 
meningeal  involvement.  In  toxic  cases  of  such  a  nature  the  evidence 
supplied  by  the  absence  of  the  distended  fontanel,  the  absence  of  eye 
symptoms,  and  the  absence  of  the  respiratory  and  pulse  phenomena 
point  strongly  to  a  meningismus  and  not  to  a  meningitis.  It  must 
be  remembered  that  any  cardinal  symptom  of  meningitis  may  be  pres- 
ent in  one  of  these  acute  toxic  processes.  In  meningitis,  however, 
we  have  a  grouping  of  symptoms — a  symptom-complex  which  renders 
a  diagnosis  practically  positive. 

Prognosis. — The  prognosis  is  most  unfavorable.  I  have  seen  a 
large  number  of  cases,  both  in  hospital  and  private  work,  and  have 
never  known  a  recovery  of  a  proved  case.  Recoveries  have  been 
reported,  however,  by  competent  observers. 

Archanzelsky,  of  Moscow,  reports  the  recovery  of  a  girl  eight  years 
of  age  who  showed  the  characteristic  symptoms  of  the  disease,  and  in 
whose  cerebrospinal  fluid  a  large  number  of  tubercle  bacilli  were  found. 
This  writer  found  in  the  literature  instances  of  recovery  in  50  cases  of 
tuberculous  meningitis  the  existence  of  which  he  considered  proved. 

Duration. — The  duration  of  the  disease  varies.  Few  cases  pass  the 
third  week.     I  have  seen  patients  die  within  one  week  from  the  onset. 


CEREBROSPINAL    MENINGITIS  557 

My  longest  case  was  in  a  girl  three  years  old,  who  lived  six  weeks  from 
the  onset  of  the  symptoms. 

Treatment. — I  know  of  no  treatment  that  is  of  curative  value. 
For  the  comfort  of  the  family  and  the  relief  of  symptoms  the  meas- 
ures suggested  under  the  treatment  of  simple  meningitis  (p.  552) 
may  be  followed  out. 

Withdrawal  of  the  cerebrospinal  fluid,  removing  the  pressure  within 
the  cranium,  may  furnish  temporary  relief  from  the  very  active  symp- 
toms of  convulsions,  restlessness,  and  muscle  contractions.  The  fluid 
returns,  however,  and  the  fontanel,  which  was  sunken  after  the 
tapping,  is  soon  bulging  as  much  as  before.  The  therapeutic  value 
of  the  lumbar  puncture,  according  to  my  observation,  is  nil. 

CEREBROSPINAL  MENINGITIS 

In  1866  Samuel  Webber  recorded  over  a  score  of  epidemics  occur- 
ring between  the  fourteenth  and  nineteenth  centuries,  which  presented 
the  features  of  this  form  of  meningitis,  giving  rise  to  such  designations 
as  "typhus  syncopalis"  "petechial  fever,"  fievre  cerebrale,"  and 
"cephalogie  epidemique." 

Danielson  and  Mann  describe  an  epidemic  which  attacked  Massa- 
chusetts in  1806,  and  in  1811  Elisha  Hirth  published  a  very  full 
account  of  "a  malignant  epidemic  called  "spotted  fever."  Since  this 
period,  according  to  Dr.  A.  Jacobi,  outbreaks  of  the  disease  have  been 
more  extensive  in  America  than  in  any  other  country.  In  the  years 
1904  and  1905  New  York  city  underwent  a  very  severe  epidemic,  which 
caused  about  3400  deaths,  and  in  the  winter  of  1904  attained  a  mor- 
tality of  91  per  cent.  At  this  time  a  commission  appointed  to  investi- 
gate the  disease  reported  the  presence  of  the  meningococcus,  as  shown 
by  cultures  from  the  nasal  mucosa,  in  50  per  cent,  of  the  patients  and 
in  10  per- cent,  of  their  attendants.  This  organism,  also  known  as 
the  Diplococcus  intracellularis  of  Weichselbaum,  was  discovered  in 
1887.  Heubner  first  showed  the  existence  of  the  same  agent  in  the 
spinal  fluid  of  a  living  patient. 

Cerebro-spinal  meningitis  occurs  sporadically  and  in  epidemic  form. 

The  extreme  irregularity  remarked  by  many  observers  in  the  spread 
of  epidemic  meningitis  has  led  one  to  state  that  "from  the  practical 
clinical  standpoint  the  etiology  is  about  the  same  as  for  death  by  light- 
ning." In  the  past  the  mortality  has  ranged  from  50  to  100  per  cent. 
With  the  adoption  of  serum  therapy,  however,  the  death-rate  has  been 
universally  lowered,  and  in  1908  Flexner  and  Jobling  were  able  to 
report  a  total  of  nearly  400  cases  in  which  their  serum  had  been  used, 
with  a  mortality  of  only  25  per  cent.,  while  in  the  cases  most  promptly 
treated  the  death-rate  was  considerably  lower. 

Bacteriology. — The  disease  is  due  to  the  Diplococcus  intracellularis 
of  Weichselbaum,  which  has  become  known  as  the  Meningococcus  intra- 
cellularis, and  is  universally  acknowledged  as  the  infecting  agent  in 
the  disease. 


558  THE    PRACTICE    OF    PEDIATRICS 

This  organism  had  been  found  in  the  blood,  lungs,  and  joints.  It 
has  never  been  demonstrated  as  existing  outside  of  the  body. 

Pathology. — Meningococci  are  not  all  identical  in  their  serological 
reactions;  but  fall  into  two  main  groups  which  have  been  termed  "nor- 
mal" and  parameningococcus"  strains.  Many  strains  should  be  em- 
ployed in  making  a  polyvalent  serum  for  therapeutic  use,  in  order  that 
immune  bodies  in  both  groups  of  meningococci  may  be  produced.  The 
parameningococci  were  first  described  by  Dopter,  who  isolated  them 
from  the  nasal  secretion  and  later  they  were  found  in  the  spinal  fluid 
of  cases  of  cerebro-spinal  meningitis.  There  are  no  morphological  nor 
biological  differences  between  the  two  types  of  meningococci. 

Notwithstanding  the  general  nature  of  this  disease,  as  shown  by 
its  fulminant  course  and  the  existence  of  such  symptoms  as  petechise,. 
purpura,  and  herpes,  the  lesions  produced  are  quite  closely  limited 
to  the  central  nervous  system.  Here  the  conditions  found  in  cases- 
of  simple  meningitis  are  roughly  simulated.  Enlargement  of  the 
spleen,  multiple  abscesses,  acute  nephritis,  hepatic  degeneration,  and 
pneumonia  may  also  be  found. 

The  exudate  covering  the  brain  is  usually  lighter  in  color  and 
thinner  than  in  pneumococcus  meningitis  and  in  sporadic  cases  of  the 
meningococcus  type.  The  cord  and  base  of  the  brain  only,  or  even  the 
cord  alone,  may  show  the  presence  of  the  lesions.  The  affected  por- 
tions of  the  brain  are  covered  with  seropurulent  or  fibrinopurulent 
exudate,  and  the  cerebral  convolutions  are  more  or  less  flattened^ 
depending  on  the  degree  of  accompanying  hydrocephalus. 

The  hydrocephalus  is  caused  by  closure  of  the  foramen  of  Magendie- 
by  inflammatory  exudate,  either  recent  or  organized. 

In  very  malignant  cases  the  gross  changes  in  the  meninges  are  not 
marked  because  the  disease  runs  its  course  so  rapidly,  but  the  mem- 
branes show  congestion  and  dulness  and  microscopically  many 
polynuclear  leukocytes  and  cocci  are  found  on  the  surface  of  the 
pia  arachnoid. 

The  Cerebrospinal  Fluid. — The  cerebrospinal  fluid  is  turbid.  Whe- 
ther it  is  greatly  increased  in  amount  or  not  depends  upon  the  severity 
of  the  infection.  The  cells  present  are  polynuclear  leukocytes  and 
meningococci  are  found  within  them  and  outside  as  well. 

Transmission. — That  the  disease  may  be  transmitted  from  those 
affected  to  the  well  has  never  been  proved,  and  it  cannot  positively  be 
placed  in  the  communicable  class,  although  such  action  has  been  taken 
by  the  New  York  Health  Department.  It  is  extremely  rare  for  twO' 
cases  to  develop  in  the  same  family,  even  when  no  quarantine  is  estab- 
lished. I  have  seen  many  patients  admitted  to  hospital  wards  contain- 
ing other  children,  and  have  never  known  a  new  case  to  develop  under 
such  conditions.  Epidemics  occur  at  different  times  in  different  lo- 
calities without  assignable  cause.  Several  children  become  ill  in  a, 
given  locality,  covering  perhaps  a  period  of  two  or  three  months,  and 
then  the  disease  disappears. 

Various  theories  have  been  advanced  from  time  to  time  as  to  the 


CEREBROSPINAL    MENINGITIS  559 

mode  of  entrance  of  the  meningococcus  into  the  body.  All  the  cases 
in  a  given  epidemic  are  evidently  infected  from  the  same  source. 
One  of  the  means  of  infection  is  probably  through  the  inspired  air. 
The  meningococcus  has  been  found  by  different  observers,  as  men- 
tioned above,  in  the  mucous  membrane  of  the  nose. 

Age. — The  disease  is  one  of  childhood.  It  may  occur  in  earliest 
infancy,  however,  or  in  extreme  old  age.  From  two  to  ten  years  ap- 
pears to  be  the  most  susceptible  age.  Rotch  had  a  patient  six  days  old. 
Koplik's  youngest  patient  was  four  months  of  age. 

Symptoms. — In  common  with  all  diseases  in  which  the  infecting 
agent  is  microbic  in  character,  cerebrospinal  meningitis  may  exist  in 
so  mild  a  form  that  it  is  not  suspected,  or  it  may  be  sufficiently  severe 
to  take  the  life  of  the  child  in  a  few  hours. 

Illustrative  Cases. — During  the  epidemic  of  1904  and  1905  in  New  York  city,  I 
showed  two  patients — one  a  child  of  nine  months,  and  one  a  child  of  four  years  of 
age — to  my  students  at  the  New  York  Polyclinic  Medical  School  and  Hospital. 
In  neither  child  could  the  men  on  the  benches  discover  anything  wrong.  In  the 
younger  child  the  only  symptom  was  a  rather  full  fontanel  and  a  tendency  to 
drowsiness  when  left  alone.  At  that  time  his  cerebrospinal  fluid  contained  the 
meningococcus.  The  four-year-old  child  had  headache  and  some  photophobia, 
and  was  extremely  irritable.  There  had  been  vomiting,  and  there  was  an  irregu- 
larity in  the  heart  action.  This  boy  sat  up,  answered  questions,  and  did  not  appear 
at  all  ill.  The  day  previous,  meningococcus  had  been  found  in  the  cerebrospinal 
fluid.     Both  children  recovered  without  treatment. 

Fulminating  Cases. — On  the  other  hand,  during  the  same  epidemic 
a  girl  of  eight  years  was  taken  ill  with  the  disease  in  the  early  morning 
and  died  about  10  o'clock  at  night  on  the  same  day.  This  very  severe 
form  is  usually  found  among  the  earlier  cases  in  an  epidemic.  The 
symptoms  of  these  fulminating  cases  are  from  the  onset  most  severe. 
The  child  is  literally  ''struck  down. "  The  earliest  symptom  may  be  a 
violent  chill,  followed  by  fever,  or  the  initial  symptom  may  be  a  con- 
vulsion. If  there  is  a  convulsion  at  this  period,  the  child  rarely  comes 
completely  out  of  it.  Active  vomiting  may  be  present.  Extreme  irrit- 
ability usually  precedes  the  comatose  state,  which  rapidly  supervenes. 
Whatever  may  be  the  early  manifestations  in  any  fulminating  case, 
two  symptoms  will  always  be  present — intense  headache  and  high 
fever.  The  heart  action  becomes  very  rapid,  breathing  is  superficial 
and  irregular,  the  pupils  show  no  response  to  light,  and  the  child  can- 
not be  roused.  Rigidity  of  the  neck  muscles  and  general  muscle 
contractions  may  be  present.  There  is  intense  hyperesthesia,  the 
shghtest  sound  or  touch  being  acutely  felt  and  resisted.  I  have  seen 
the  child  throw  himself  about  during  the  first  hours  so  that  he  was 
with  difficulty  kept  in  bed. 

Petechise  appear,  and  ecchymotic  areas  soon  are  scattered  over  the 
surface.  This  symptom,  however,  does  not  occur  in  all  cases.  Exten- 
sive hemorrhagic  purpura  is  of  occasional  occurrence  in  cerebro- 
spinal meningitis.  I  have  seen  two  such  cases  in  which  large  areas 
of  the  body  surface  were  involved  in  subcutaneous  hemorrhage. 
It  is  peculiar  that  in  these  cases  the  nervous  manifestations  were 


560  THE    PRACTICE    OF    PEDIATRICS 

much  less  pronounced  than  in  the  average  case.  Diagnosis  was  proven 
by  the  typical  findings  in  the  cerebro-spinal  fluid. 

Between  the  mild  and  fulminating  types  of  the  disease  symptoms  of 
any  degree  may  exist,  indicating  the  varying  degrees  of  virulency  of  the 
infection.  As  a  rule,  the  onset  is  more  abrupt  than  in  other  forms  of 
meningitis.  Headache  is  a  fairly  constant  symptom  in  all  cases.  This 
will  be  evidenced  by  complaint  on  the  part  of  the  child  or  in  younger 
children  by  head-rolling,  or  head-boring,  or  striking  the  head  with  the 
hands. 

Position  of  Patient. — The  position  of  the  child  when  the  case  is  fully 
developed  is  characteristic.  The  patient  rests  on  his  side;  the  head  is 
retracted,  the  knees  are  drawn  up,  and  the  legs  are  flexed  on  the  thighs; 
the  arms  are  flexed  and  the  hands  clinched. 

The  Fontanel. — The  distention  of  the  fontanel  in  the  younger 
patients  is  a  constant  and  very  reliable  sign. 

The  Temperature. — The  temperature  is  variable  and  irregular — now 
high,  now  low;  there  is  no  characteristic  temperature  range  in  the  disease. 

Convulsions  occur  in  a  majority  of  the  cases.  There  is  always  hy- 
peresthesia, and  evidence  of  much  discomfort  when  the  child  is  handled. 

Muscle  rigidity  is  usually  present,  even  in  the  milder  cases.  The 
entire  body  may  be  involved  and  become  stiff  and  rigid,  or  a  muscle 
group  only  may  be  involved.  Rigidity  of  the  neck  and  some  degree 
of  opisthotonos  are  rarely  absent,  except  in  the  milder  cases.  The 
feet  are  held  in  a  position  of  extension.  Swallowing  is  difficult  or  im- 
possible, and  toward  the  end,  in  fatal  cases,  gavage  has  to  be  resorted 
to.  In  the  recovery  cases,  also,  during  the  active  stages  of  the  disease, 
this  measure  may  be  necessary  to  sustain  the  patient. 

Heart  and  Respiration. — The  heart  action  is  much  disturbed.  It 
may  be  very  rapid  or  slow.  The  usual  condition  is  that  of  slowness 
and  irregularity. 

The  respiration  likewise  is  slow  and  irregular,  and  may  assume  the 
Cheyne-Stokes  type. 

Mental  Apathy. — The  child  becomes  extremely  dull,  and  is  aroused 
with  difficulty.  From  this  condition  he  may  recover,  or,  what  is  more 
frequently  the  case,  he  passes  into  a  condition  of  stupor  and  coma. 

Bowel  Conditions. — The  bowels  are  usually  constipated  and  the  ab- 
domen is  retracted.  These  symptoms,  made  much  of  by  writers,  are 
very  variable  and  may  or  may  not  be  present  in  severe  cases. 

The  Eyes. — The  eyes  frequently  show  strabismus.  The  pupils  are 
usually  dilated,  often  unequal  in  size,  and  show  no  response  to  light, 
or  react  but  slowly. 

The  Ears. — Deafness  may  occur  early  and  continue  throughout. 
In  the  absence  of  local  ear  changes  it  is  due  to  an  inflammatory  in- 
volvement of  the  auditory  nerve. 

The  Skin. — In  but  a  few  cases  seen  by  me  have  there  been  skin 
changes.  Petechise  and  ecchymoses  have  been  seen  in  the  very  malig- 
nant forms.  The  skin  in  the  mild  and  moderately  severe  cases  has 
remained  negative. 


CEREBROSPINAL    MENINGITIS  561 

Symptoms  in  Recovery  Cases. — In  a  case  in  which  there  has  been 
a  moderately  severe  infection  and  which  goes  on  to  recovery,  there  is 
a  train  of  symptoms  which  indicates  the  favorable  outcome. 

As  might  be  expected,  a  general  clearing  of  the  dulled  mentahty  is 
one  of  the  earliest  and  most  favorable  signs.  The  temperature,  which, 
though  variable  as  to  degree,  is  almost  always  present,  subsides.  The 
child  evidences  a  desire  for  food,  and  makes  attempts  at  using  his  stiff- 
ened muscles.  Muscle  rigidity  is  the  last  symptom  to  disappear.  I 
have  repeatedly  known  children  to  talk,  to  play,  and  be  interested  in 
their  surroundings;  in  fact,  apparently  well,  with  the  exception  of  the 
muscle  contraction  which  held  them  in  the  characteristic  position  of 
opisthotonos. 

Illustrative  Case. — A  child  seen  at  various  times  in  consultation  with  a  colleague 
was  blind  for  six  weeks,  absolutely  deaf  for  three  months,  and  on  his  back  for  five 
months,  yet  made  a  perfect  recover5^  Toward  the  end  he  was  emaciated  to  a  skele- 
ton. I  saw  the  boy  on  three  occasions,  and  each  time  made  a  fatal  prognosis. 
Four  months  after  my  last  fatal  prognosis  I  saw  the  boy  on  the  street  playing  with 
other  boys. 

Diagnosis. — Abrupt  onset  is  the  rule.  Convulsion,  vomiting  with- 
out apparent  cause,  chill,  headache,  more  or  less  intense  photophobia, 
hyperesthesia,  rigidity  of  the  neck  muscles,  and  fever  constitute  the 
earliest  diagnostic  signs.  Such  a  symptom-complex,  followed  by 
drowsiness  and  stupor,  warrants  the  use  of  lumbar  puncture  (p.  566) 
to  determine  positively  the  presence  of  meningitis.  This  should  be 
done  in  all  suspected  cases  so  as  to  give  the  patient  the  benefit  of  the 
Flexner  serum  at  the  earliest  possible  moment.  The  later  manifesta- 
tions of  the  disease  are  unmistakable.  The  rigid  neck,  opisthotonos,  the 
dilated,  unequal  and  immobile  pupils,  the  slow,  irregular  respiration, 
and  slow,  irregular  pulse,  comprise  a  group  of  diagnostic  signs  found 
only  in  meningitis. 

Hyperesthesia  is  always  present.  The  child  almost  invariably 
cries  when  disturbed  or  handled  in  any  way,  while  his  mentality  is  still 
able  to  appreciate  the  disturbance. 

Kernig's  Sign. — This  consists  in  an  inability  to  extend  the  leg  on 
the  thigh  when  the  latter  is  flexed  on  the  abdomen.  The  sign  is  present 
and  is  fairly  reliable  in  children  over  two  and  one-half  years  of  age. 
In  younger  children,  particularly  those  under  eighteen  months,  because 
of  the  normal  tendency  to  contraction  of  the  flexor  muscles  at  this 
period  of  life,  the  sign  is  of  less  value. 

Kernig's  sign  is  also  present  in  other  cerebral  lesions  and  in  other 
forms  of  meningitis. 

Babinski's  phenomenon  consists  in  an  extension  of  the  great  toe 
and  a  flexion  and  separation  of  the  remaining  toes  when  the  plantar 
surface  of  the  foot  is  stroked  with  the  finger.  This  sign  is  often  absent, 
and  is  of  corroborative  value  only  in  the  event  of  other  symptoms. 
Its  presence  may  be  an  indication  of  meningitis,  and  its  absence  is  of 
no  significance.  I  have  produced  this  reflex  repeatedly  in  normal  chil- 
dren under  eighteen  months  of  age. 

The  tache  cerebrale  may  be  demonstrated  in  practically  every  case. 
36 


562  THE    PEACTICE    OF    PEDIATRICS 

The  patellar  reflex  is  variable  and  uncertain.  It  may  be  increased, 
diminished,  or  absent,  and  is  of  httle  diagnostic  value. 

The  Eye  Changes. — The  pupils  are  usually  dilated,  often  unequal, 
and  may  show  no  response  to  light  or  react  slowly. 

Strabismus  is  always  present  at  some  stage.  The  eye-grounds  may 
show  retinitis,  choroiditis,  or  neuritis  of  the  optic  disk.  In  the  pro- 
longed cases  conjunctivitis  and  keratitis  are  often  present. 

Heart  Action. — The  pulse  is  slow  and  irregular.  It  may  be  inter- 
mittent, or  now  and  then  a  case  will  be  seen  in  which  the  pulse  is  very 
rapid — 160  to  200 — with  a  normal  temperature. 

The  respiration  is  likewise  disturbed,  slow,  and  of  the  Cheyne- 
Stokes  tj^pe.  The  respiration  is  very  changeable  at  an  examination, 
the  rate  being  now  slow  .and  irregular,  now  very  rapid. 

The  temperature  range  is  in  no  way  diagnostic,  although  tempera- 
ture is  usually  present. 

Emaciation. — There  is  such  a  marked  loss  in  weight  that  the  emacia- 
tion may  be  looked  upon  as  one  of  the  symptoms  of  the  disease.  In 
all  cases  there  is  wasting,  and  the  longer  the  case,  the  greater  is  the 
emaciation. 

A  ward  filled  with  these  emaciated  children,  with  their  dulled,  star- 
ing eyes  and  bent,  rigid  trunks  and  limbs,  furnishes  a  most  pitiful  and 
gruesome  picture. 

Differential  Diagnosis. — In  spite  of  the  foregoing  signs  and  symp- 
toms we  have  cases  of  cerebro-spinal  meningitis  which  may  only  be 
differentiated  from  other  types  by  an  examination  of  the  spinal  fluid. 

Complications. — Considering  the  nature  and  severity  of  its  symp- 
toms, cerebrospinal  meningitis  is  a  disease  with  few  complications. 
Pneumonia  is  only  an  unusual  occurrence.  Eye  involvement  is  to  be 
looked  upon  more  as  a  feature  of  the  disease  than  as  a  complication. 
Nephritis  is  exceedingly  rare.  Bed-sores  are  frequently  developed,  and 
become  a  troublesome  feature,  but  again  this  cannot  properly  be  con- 
sidered a  complication. 

Among  the  sequelae  are  idiocy,  blindness,  deafness,  epilepsy,  acute 
and  chronic  hydrocephalus,  and  spastic  paralysis  of  different  sets  of 
muscles.  I  have  several  patients  under  my  care  who  have  survived 
meningitis  and  are  considered  to  have  had  complete  recoveries,  who 
are,  nevertheless,  backward  in  school,  have  severe  headaches,  or  who 
show  marked  absence  of  control. 

Duration. — The  duration  of  the  disease  depends  largely  upon  the 
nature  of  the  infection.  Death  may  take  place  in  a  few  hours,  or  the 
patient  may  linger  for  weeks.  A  boy  twelve  years  of  age,  whom  I 
cared  for  several  years  ago,  died  from  exhaustion  in  the  twentieth 
week  of  the  disease.  I  have  repeatedly  seen  children  make  partial  re- 
coveries and  linger  for  several  weeks  in  a  wretched,  emaciated  condition 
and  eventually  die  from  asthenia.  Others  make  incomplete  recoveries 
which  place  them  in  the  dependent  class  for  the  remainder  of  their  lives. 

Treatment  of  Cerebrospinal  Meningitis. — The  medication  and 
general    management    in  cerebrospinal  meningitis  are  the  same  as 


CEREBROSPINAL    MENINGITIS 


563 


suggested  for  acute  infective  meningitis  (p.  551).  Little  or  nothing  is 
to  be  expected  from  drugs,  except  such  as  may  be  used  for  palliative  or 
laxative  purposes. 

Serum  Treatment. — The  Flexner  serum  is  the  only  means  of  treat- 
ment at  our  command  which  promises  any  curative  effects  in  the  dis- 
ease. In  1904  Flexner  produced  an  anti-meningitic  serum  for  the  treat- 
ment of  cerebro-spinal  meningitis.  Horses  were  immunized  by  graded 
injections  of  cultures  of  the  diplococcus  intracellularis  and  its  toxin. 
He  distributed  this  serum  to  many  observers  throughout  the  world  and 
in  1913  made  a  final  report  of  1294  cases  which  had  been  treated  with 
this  serum,  which  is  injected  intraspinally.  The  effect  of  the  serum 
is  partly  bactericidal,  partly  by  bringing  about  phagocytosis  and 
probably  partly  by  an  antitoxic  reaction.  Previous,  to  the  use  of  the 
serum  the  mortality  ranged  from  50  per  cent,  to  90  per  cent. ;  since  its 
use  the  mortality  has  been  reduced  from  20  per  cent,  to  30  per  cent. 
The  following  are  the  statistics  of  results  as  compiled  by  Flexner.* 

MORTALITY  ACCORDING  TO  AGE 


Age 

Cases 

Recoveries 

Deaths 

Mortality 

Under  1  year 

129 

87 

194 

218 

360 

288 

18 

1294 

65 
60 
139 
185 
254 
180 
11 
894 

64 

27 

55 

33 

106 

108 

■  7 

400 

49.6 

Between  1  and  2  years 

Between  2  and  5  years 

Between  5  and  10  years 

Between  10  and  20  years.  .  .  . 

Over  20  years 

Age  not  given.              .  .  . 

31.0 

28.4 
15.1 
29.4 
'37.5 
38.9 

Total 

30.9 

MORTALITY  ACCORDING  TO  PERIOD  OF  FIRST  INJECTION 


Period  of  Injection                           Cases 

Recoveries 

Deaths 

Mortality 

1st  to  3d  day 

199 

346 

666 

1211 

163 
252 
423 

838 

36 

94 

243 

373 

18.1 

4th  to  7th  day 

27.2 

Later  than  7th  day 

36.5 

Total 

30.8     • 

The  average  mortality  rate  of  the  patients  of  19  observers  who  have 
published  their  results  in  the  literature  was  29  per  cent.  This  com- 
pilation totals  4664  cases  with  1338  deaths. 

The  use  of  serum  gives  the  best  results  when  injected  early  and  in 
children  between  the  ages  of  5  and  10  years.  The  serum  is  useful,  how- 
ever, even  if  injected  late  in  the  disease.  Infants  under  one  year  do  not 
respond  readily  to  the  serum.  With  the  use  of  the  serum  30  per  cent, 
of  the  favorable  cases  terminate  abruptly,  while  without  serum  crises 
are  unusual.  When  the  first  injection  is  made  within  the  first  three 
days,  50  per  cent,  terminate  by  crisis.     There  has  also  been  a  re- 

*  Journal  Exp.  Medicine,  May,  1913. 


564  THE    PRACTICE    OF    PEDIATRICS 

markable  reduction  in  the  severity  and  number  of  complications  by 
the  use  of  serum.  Out  of  894  children  in  Flexner's  series  who  re- 
covered, 68  or  73^^  per  cent,  had  complications  as  follows: 


39  cases 

Total  deafness 

4.4  per  cent. 

6  cases 

Partial  deafness 

0.7  per  cent. 

3  cases 

Total  blindness 

0.3  per  cent. 

6  cases 

Partial  blindness 

0.7  per  cent. 

3  cases 

Impaired  mentality 

0.3  per  cent. 

11  cases 

Paralysis 

1  per  cent. 

There  have  been  some  noteworthy  improvements  made  in  the  serum 
since  it  was  first  produced.  Many  children  were  found  who  did  not 
react  favorably.  Investigations  proved  that  there  are  many  strains  of 
the  meningococcus;  notable  among  these  is  the  parameningococcus. 
Horses  used  to  supply  the  serum  are  now  injected  with  the  cultures  of 
these  different  strains. 

Because  of  the  prevalence  of  the  disease  among  the  soldiers  at  the 
front  on  the  continent,  it  was  found  necessary  to  hasten  the  production. 
Wollstein  and  Amoss*  have  perfected  a  method  by  which  the  serum  can 
be  produced  in  8  to  12  weeks  instead  of  6  to  12  months  as  heretofore. 

Method  of  Use. — The  first  injection  of  serum  is  given  in  a  suspected 
case  as  soon  as  turbid  fluid  is  withdrawn;  without  waiting  for  bacterio- 
logical examination.  It  is  best  to  withdraw  all  the  fluid  possible  at 
each  puncture  and  then  inject  25  to  35  c.c.  of  serum  by  the  gravity 
method.  One  injection  rarely  suffices.  Four  injections  given  daily 
is  the  average,  but  some  patients  require  as  many  as  twelve.  In  the 
very  severe  cases  the  second  injection  should  follow  in  twelve  hours. 
Even  though  an  injection  does  not  seem  necessary  a  puncture  should 
be  done  every  day  or  two  during  the  course  of  the  disease  for  bacterio- 
logical examination.  The  most  important  indication  for  an  injection 
is  the  clinical  aspect  of  the  patient.  Even  though  the  fluid  becomes 
clear  and  no  diplococci  are  found,  if  there  is  persistent  Kernig's  sign, 
iregularity  of  temperature  or  mental  symptoms,  a  repetition  of  the 
injections  is  necessary. 

Soon  after  one  or  two  injections  of  the  serum  in  favorable  cases,  the 
diplococci  in  smears  are  greatly  reduced  in  number,  become  intracellu- 
lar, and  finally  disappear.  The  organisms  should  also  present  changes 
in  appearance,  as  swelling  and  fragmentation,  stain  diffusely  and  in- 
distinctly and  lose  their  mobility  in  cultures.  The  purulent  appear- 
ance of  the  spinal  fluid  becomes  more  translucent  and  finally  clears.  A 
reduction  of  the  leukocytes  in  the  blood  follows  if  the  serum  is  success- 
fully combating  the  disease. 

Technic  of  Serum  Injection. — The  patient  is  placed  in  the 
usual  recumbent  position  for  spinal  puncture.  If  an  infant,  and 
can  be  properly  held  by  an  assistant,  no  anesthetic  is  necessary. 
Chloroform  had  best  be  administered  to  the  older  children  who 
resist  holding.  The  gravity  method  is  preferable  to  the  syringe. 
Sophian  of   New     York    has    perfected    a    blood    pressure    control 

*  Journal  of  Exp.  Med.,  May,  1916. 


MENINGISMUS    (SEROUS    MENINGITIS)  565 

for  the  withdrawal  of  fluid  and  the  injection  of  serum.  When  the  spinal 
fluid  is  being  withdrawn  there  should  be  a  drop  of  not  more  than  5  to  10 
mm.  of  mercury.  In  case  of  a  further  drop  no  more  fluid  is  removed. 
The  funnel  of  the  apparatus  is  filled  with  serum  which  has  been  heated 
to  body  temperature.  All  air  should  be  carefully  eliminated  from  the 
connecting  tube.  The  funnel  is  gradually  raised  to  permit  the  serum  to 
flow  in  gradually  by  gravity.  It  is  seldom  possible  to  inject  as  much 
serum  as  fluid  withdrawn  without  disconcerting  symptoms.  If  the 
blood  pressure  drops  10  mm.  of  mercury  the  process  should  be  tem- 
porarily discontinued  until  the  normal  blood  pressure  is  restored,  at 
least  in  part.  Where  the  pressure  continues  to  fall,  discontinue  the 
injection.  It  is  always  a  wise  precaution  to  keep  the  tube  connected 
for  three  minutes  after  the  injection,  so  that  the  serum  may  be  with- 
drawn by  lowering  the  tube  if  the  child  shows  a  falling  pressure,  dilata- 
tion of  the  pupils  or  shallow  irregular  respirations.  If  these  symptoms 
supervene,  the  head  should  be  raised  and  injections  of  atropin  and 
adrenalin  administered  intramuscularly. 

The  spinal  fluid  in  some  cases  will  become  clear  and  show  very  few 
meningococci  and  yet  the  fever  and  prostration  continue.  This  is  due 
to  adhesions  or  thick  exudate  at  the  base  of  the  brain  which  does  not 
allow  the  serum  to  reach  the  meninges  or  the  lateral  ventricles.  When 
this  occurs  it  is  necessary  to  puncture  the  ventricle  through  the  an- 
terior fontanelle,  withdraw  the  fluid  and  inject  the  serum.  In  older 
children,  trephining  may  be  necessary.  Another  not  unusual  obstacle 
to  the  treatment  with  serum  is  a  very  thick  gelatinous  fluid  which  is 
withdrawn  with  difficulty.  In  such  cases  Sophian  recommends  care- 
ful irrigation  with  normal  saline  to  aid  the  withdrawal  of  the  fluid. 

Vaccines. — The  first  cultures  obtained  are  used  for  the  preparation 
of  an  autogenous  vaccine.  This  is  used  if  the  case  takes  a  chronic 
course.  Subcutaneous  injections  on  alternate  days  ranging  from  200 
million  to  2000  million  are  given,  increasing  by  200  million  at  each 
injection.     As  many  as  10  injections  are  given  if  necessary 

MENINGISMUS  (SEROUS  MENINGITIS) 

Meningismus  is  a  term  first  employed  by  Dupre  to  describe  cere- 
bral intoxication,  a  condition  clinically  closely  resembling  meningitis, 
in  which  the  spinal  fluid  is  sterile.  This  condition  may  occur  in  any 
very  severe  illness  of  infancy  or  childhood.  It  may  occur  in  typhoid, 
acidosis,  acute  gastro-enteric  intoxication,  influenza,  pneumonia  or  any 
of  the  exanthemata.  Very  severe  scarlet  fever  is  apt  to  be  accom- 
panied by  meningismus. 

Symptoms. — There  may  be  stupor,  coma  or  convulsions,  retraction 
of  the  head,  vomiting  and  twitchings  of  the  face  or  various  parts  of  the 
body.  In  fact  the  symptoms  so  closely  resemble  true  meningitis  and 
acute  polio-encephalitis  that  a  differentiation  is  only  possible  in  some 
instances  by  means  of  the  lumbar  puncture. 

Diagnosis  and  Differential  Diagnosis. — In  true  meningitis,  whether 
simple,  acute  cerebrospinal  or  tubercular,  microorganisms  are  present 


566 


THE    PRACTICE    OF   PEDIATRICS 


in  the  cerebrospinal  fluid,  the  cell  count  is  increased  and  globulin  is 
usually  present.  The  pupils  may  be  dilated  or  contracted  and  show 
slow  response  to  light,  but  in  meningismus  they  act  together  and 
evenly.  I  have  never  seen  the  symptom  of  absence  of  coordination  of 
the  pupils  that  was  not  true  meningitis.  The  eye-ground  changes 
in  meningismus  are  negUgible. 


lumbar    puncture. 


Further  it  is  to  be  remembered  that  in  meningismus  there  is  usually 
the  association  of  other  diseases,  and  the  cerebral  signs  are  secondary. 

Lumbar  Puncture. — In  any  case  showing  active  cerebral  symptoms, 
a  lumbar  puncture  should  always  be  made. 

Treatment. — The  treatment  is  covered  in  the  management  of  the 
disease  with  which  the  meningismus  is  associated. 

LUMBAR  PUNCTURE 

The  site  selected  for  lumbar  puncture  is  on  a  line  between  the  crests 
of  the  ilia  and  between  the  spinous  processes  of  the  third  and  fourth 
lumbar  ve^-tebrae. 


Fig.   76. — Quincke's  needle. 


Position  of  the  Patipnt. — The  child  should  rest  on  one  side  (see  Fig. 
75),  sufficient  pressure  being  exerted  on  the  buttocks  to  make  the  spin- 
ous processes  prominent.  The  Quincke  needle  (Fig.  76)  should  al- 
ways be  used  in  making  the  puncture.  The  stylet  which  fits  the 
beveled  edge  of  the  point  of  the  needle  effectually  prevents  its  being 
plugged. 

Method. — The  skin  for  several  inches  about  the  site  of  the  puncture 


LUMBAR    PUNCTURE  567 

should  be  scrubbed  with  the  tincture  of  green  soap  and  alcohol.  The 
physician's  hands  should  be  thoroughly  disinfected.  Considerable 
force  may  be  necessary  in  order  to  enter  the  canal.  When  there  is  a 
sudden  giving  way  of  the  obstruction  to  the  progress  of  the  needle,  one 
may  know  that  the  canal  has  been  entered.  The  puncture  may  be 
made  in  a  line  with  the  spinous  processes  or  from  the  side,  the  needle 
being  passed  between  the  laminse  and  inward  about  one  inch.  When 
the  point  of  the  needle  has  been  introduced  into  the  spinal  canal,  the 
stylet  is  withdrawn.  The  cerebrospinal  fluid  may  escape  with  force  in 
a  stream  as  a  result  of  the  pressure  or  it  may  exude  drop  by  drop.  A 
sterile  tube  should  be  in  readiness  in  order  to  collect  the  fluid  for  ex- 
amination. In  dealing  with  older  children  after  the  third  year  it  is 
often  easier  to  introduce  the  needle  slightly  to  the  right  or  left  of  the 
line  of  the  spinous  process. 

When  the  canal  is  entered  and  the  cerebrospinal  fluid  does  not  pass 
readily  through  the  needle,  the  flow  may  be  increased  by  elevating  the 
child  almost  into  a  sitting  position  with  the  head  forward.  A  dry  tap 
usually  means  that  the  canal  has  not  been  entered.  For  some  children 
it  will  be  necessary  to  employ  a  slight  degree  of  anesthesia.  I  have 
used  both  gas  and  chloroform  for  this  purpose. 

Uses  of  the  Lumbar  Puncture. — The  uses  of  lumbar  puncture  are 
threefold:  for  diagnostic  purposes;  as  a  means  of  conveyance  of  sera 
to  the  spinal  canal,  and  for  the  relief  of  acute  symptoms  by  the  with- 
drawal of  the  fluid,  thereby  relieving  pressure. 


XIV.  DISEASES  OF  THE  SKIN 

The  skin  of  an  infant  is  to  be  looked  upon  as  an  organ  with  impor- 
tant functions  to  perform.  On  account  of  its  location  it  is  the  most 
exposed  organ  of  the  body;  among  its  most  important  functions  is, 
therefore,  protection  of  the  underlying  structures. 

In  the  skin,  moreover,  are  located  the  most  important  organs  of 
excretion,  the  sweat-glands,  as  well  as  those  very  delicate  nerve  struc- 
tures, the  tactile  organs.  Through  the  skin,  heat  radiation  is  carried 
on  by  means  of  the  circulating  blood  in  the  capillaries.  When  we  con- 
sider the  active  metabolic  processes  that  are  taking  place  in  the  infant 's 
body,  it  is  not  hard  to  appreciate  the  amount  of  work  the  skin  is  called 
upon  to  do  in  performing  its  functions  of  excretion  and  heat  radiation. 

Care  of  Skin  in  Health. — The  skin  in  the  infant  is  particularly  deH- 
cate,  and  responds  very  readily  to  external  irritation  of  any  nature. 
Excessive  clothing  at  any  time  of  the  year,  but  more  particularly  in 
summer,  produces  the  well-known  prickly  heat  or  sudamina.  Eczema 
may  result  from  the  irritant  effects  of  improper  clothing. 

The  different  forms  of  intertrigo  are  the  result  of  irritation  produced 
by  the  contact  of  unclean  napkins  containing  urine  or  feces  or  both. 
In  order  to  avoid  intertrigo  the  napkin  must  be  changed  during  the 
waking  hours  whenever  the  urine  is  voided.  In  some  instances  it  is  not 
well  to  wake  a  child  for  a  change  of  napkin  because  of  urination ;  and 
at  other  times  during  the  day,  such  as  the  outing  period,  the  clothing 
cannot  always  be  changed  in  the  park  or  street.  Under  such  circum- 
stances a  prophylatic  measure  should  be  employed.  Over  the  groin 
and  folds  of  the  buttocks  should  be  spread  pieces  of  old  linen  which  have 
been  well  smeared  with  the  following  ointment : 

I^     Cerse  albaj 5  iv 

Ungt.  zinci  oxidi q.  s.  ad  §iv 

The  addition  of  white  wax  to  zinc  oxid  ointment  acts  as  a  water- 
proof dressing  to  the  skin,  and  protects  it  from  the  irritating  products 
of  decomposing  urine. 

Clothing  that  is  applied  too  tightly  will  act  as  an  irritant  to  many 
skins.  To  many  wool  acts  as  a  decided  irritant,  and  frequently  it  must 
be  avoided.  In  some  instances  it  has  been  necessary  to  line  the  child 's 
undergarments  with  thin  old  linen,  such  as  a  handkerchief.  Linen 
mesh  underclothing  may  be  used. 

In  order  further  to  keep  the  skin  healthy,  the  child  should  be  bathed 
in  a  tub  once  a  day  with  Castile  soap,  then  carefully  dried,  and  pow- 
dered with  a  simple  powder. 

568 


MILIARIA  569 

•  The  following  powder  I  have  used  extensively  for  years: 

I^     Acidi  borici gr.  xxv 

Pulv.  amyli, 

Pulv.  zinci  oxidi aa§ss 

M.  Sig. — Apply  freely. 

I  prefer  the  evening  bath.  In  the  morning  the  child  is  sponged  with 
warm  water  and  soap  and  carefully  dried,  after  which  the  powder  is 
applied.  During  the  cold  weather  the  bathing  and  sponging  should 
be  done  in  a  warm  room  with  a  temperature  over  75°F. 

The  above  simple  means  are  all  that  are  necessary,  to  keep  the  skin 
in  a  normal  condition.  The  skin  of  some  children  is  much  more  sensi- 
tive than  that  of  others,  and  will  require  more  careful  attention. 

MILIARIA  (PRICKLY  HEAT) 

The  rash  in  prickly  heat  consists  of  multiple,  minute,  transparent 
vesicles,  due  to  an  engorgement  of  the  vessels  of  the  sweat-glands  and 
obstruction  of  their  outlets. 

Symptoms. — The  child  is  very  uncomfortable  and  restless.  The 
itching  is  evidently  very  distressing.  The  rash  described  is  character- 
istic, and  usually  appears  quite  suddenly.  The  mild  cases  are  without 
inflammation.  The  inflammation,  when  present,  produces  a  general 
erythema  with  many  reddened  papules. 

Etiology. — Nearly  every  infant  in  our  climate  suffers  from  prickly 
heat  during  the  summer.  The  condition  in  summer  is  caused  by  pro- 
fuse sweating,  incident  upon  the  hot  weather  and  independent  of  pos- 
sible overclothing;  in  winter,  by  too  hot  living  rooms  and  overclothing. 

Treatment. — Heavy  clothing  and  flannels  are  to  be  avoided.  In 
order  to  lessen  the  local  irritation,  the  garment  worn  next  to  the  skin 
should  be  lined  with  silk  or  linen,  or  linen  mesh  garments  should  be 
worn.  The  further  management  directed  both  to  the  relief  of  the  pa- 
tient and  the  cure  of  the  condition  consists  in  the  frequent  application  of 
cool  water,  either  by  means  of  a  tub-bath  or  sponging.  The  soda 
bath,  the  bran  bath,  and  the  starch  bath  (p.  780)  are  all  most  useful. 
For  purposes  of  sponging  a  solution  of  bicarbonate  of  soda  should  be 
used — ^one  tablespoonful  to  a  gallon  of  water  The  relief  afforded  the 
patient  depends  not  so  much  upon  what  is  used  in  the  water,  as  upon 
the  fact  that  plenty  of  cool  water  comes  in  contact  with  the  itching, 
burning  skin.  Ointments  and  salves  are  here  of  little  service,  as  they 
tend  to  produce  further  maceration  of  the  skin.  As  local  applications, 
powders  are  to  be  preferred  to  lotions.  A  powder  used  with  satis- 
faction for  this  condition  is  of  the  following  composition: 

I^     Acidi  salicylic! gr.  x 

Acidi  borici gr.  Ix 

Pulv.  amyli, 

Pulv.  zinci  oxidi aaoj 

This  is  to  be  dusted  freely  over  the  involved  surface  several  times  daily 
— every  hour  if  necessar5\  In  case  irritation  is  produced  b}^  the  sali- 
cylic acid,  it  may  be  omitted  or  its  strength  may  be  decreased  by  the 
addition  of  powdered  starch. 


570  THE    PRACTICE    OF    PEDIATRICS 

URTICARIA  (HIVES;  NETTLE-RASH) 

A  discussion  of  all  the  aspects  of  urticara  is  unnecessary.  Only 
those  forms  will  be  considered  which  are  peculiar  to  children. 

Acute  urticaria  is  characterized  by  the  sudden  appearance  and  dis- 
appearance upon  the  skin  surface  of  wheals  and  lumps  of  vasomotor 
origin.  The  wheals,  which  are  of  varying  size,  produce  intense  itching 
and  burning,  and  then  subside  without  desquamation  as  rapidly  as 
they  have  appeared.  The  variation  in  size  and  shape  has  given  rise  to 
a  differentiation  into  types  for  purposes  of  diagnosis. 

Distribution. — The  possibilities  of  skin  involvement  in  hives  are 
most  variable.  There  may  be  but  one  wheal,  or  the  lesions  may  cover 
a  large  portion  of  the  skin  surface.  The  involved  area  may  be  very 
small,  of  the  size  of  a  pin-head,  or  extremely  large  (giant  hives,  below) , 
occasionally  producing  marked  facial  deformity.  Thus  in  the  case  of  a 
child  of  eleven  months  who  had  been  given  an  egg  for  the  first  time  the 
face  was  so  distorted  and  grotesque  that  recognition  was  impossible. 

Etiology. — Urticaria  may  be  due  to  agencies  operating  either  from 
without  or  within  the  body.  Those  operating  from  without  include 
irritants  of  almost  any  nature,  especially  the  bites  of  insects,  and  too 
tight  clothing  or  clothing  which  may  directly  irritate  the  skin.  Contact 
with  certain  plants  may  also  produce  the  wheal  hives,  termed  "nettle- 
rash."  Such  causes  as  these,  however,  are  operative  in  comparatively 
few  cases. 

Irritation  arising  from  internal  sources  is  the  cause  of  the  condition 
in  at  least  95  per  cent,  of  the  cases.  The  use  of  certain  drugs  may  oc- 
casion sufficient  irritation  to  cause  an  outbreak.  In  not  a  few  instances 
I  have  seen  hives  due  to  quinin,  arsenic,  and  antipyrin.  The  adminis- 
tration of  antitoxin  produces  hives  in  from  15  to  20  per  cent,  of  the  cases. 
Certain  articles  of  food,  such  as  strawberries,  tomatoes,  oatmeal,  and 
buckwheat,  invariably  cause  urticaria  in  some  children.  An  attack 
may  occur  without  apparent  digestive  disturbance,  or  may  appear 
coincident  with  vomiting,  diarrhea,  fever,  and  other  acute  gastro-in- 
testinal  symptoms.  The  condition  is  due  to  a  toxin  from  alimentary 
sources  which  produces  vasomotor  disturbances  of  the  skin  blood- 
supply,  resulting  in  localized  vascular  paralysis  and  transudation. 
The  itching  is  due  to  irritation  of  the  nerve  end-organs. 

Giant  Hives  (Angioneurotic  Edema). — This  condition  is  of  com- 
paratively rare  occurrence  in  children.  I  have  seen  but  a  few  cases. 
It  is  simply  a  variety  of  urticaria  occasioned  by  causes  similar  to  those 
operative  in  other  forms.  When  it  occurs  in  children,  it  most  frequently 
involves  the  tongue  and  lip.  When  involving  the  soft  parts,  the 
lesion  may  produce  an  immense  amount  of  swelling.  This  is  particu- 
larly marked  when  the  tongue  and  lips  are  affected.  I  have  seen  the 
lips  swollen  to  several  times  their  normal  thickness.  In  a  boy  four 
years  of  age  the  tongue  and  lower  lip  were  so  greatly  swollen  that 
speaking  was  impossible  and  swallowing  difficult,  and  it  was  supposed 
that  he  had  been  given  carbolic  acid  or  some  corrosive  poison.  Such 
cases  usually  develop  suddenly  and  occasion  no  little  alarm.     In  the 


RHUS    POISONING    (iVT    POISONING)  571 

■case  referred  to  I  was  called  30  miles  into  the  country  to  see  the  child 
in  consultation.  Cases  have  been  reported  in  which  the  swelling  of 
the  tongue  was  sufficient  to  produce  suffocation  requiring  incision  to 
reduce  the  swelling. 

The  cases  seen  by  me  have  all  been  associated  with  gastro-intestinal 
disturbances.  The  swellings  ordinarily  disappear  rapidly  after  a  few 
hours,  but  not  with  the  rapidity  which  marks  their  initial  appearance. 

Treatment. — Digestive  disturbances  of  any  nature,  whether  acute 
-or  chronic,  may  cause  urticaria.  In  the  event  of  an  attack,  therefore, 
■even  though  there  be  no  active  manifestations  of  indigestion,  the  origin 
■of  the  trouble  will  usually  be  found  in  the  intestine.  A  safe  procedure 
is  to  give  two  to  four  teaspoonfuls  of  castor  oil,  or  1^-^  grains  of  calomel 
in  divided  doses,  followed  the  next  morning  by  the  citrate  or  milk  of 
magnesia.  At  the  same  time  the  diet,  regardless  of  the  age,  should  be 
reduced  to  broths  and  gruels,  to  which  toast  or  dried  bread  may  be 
added,  depending  on  the  patient 's  custom.  Milk  should  not  be  given. 
The  application  of  a  menthol  ointment  (menthol,  10  grains;  rose-water 
ointment,  1  ounce)  is  a  valuable  supplementary  measure. 

In  cases  caused  by  antitoxin  and  food  allergy,  salicylate  of  soda 
(wintergreen)  will  effect  a  termination  of  the  symptoms  sooner  than  will 
any  other  agent.  To  a  child  three  years  of  age  2  grains  of  the  salicylate 
•of  soda  may  be  given  every  two  hours,  with  4  grains  of  the  bicarbonate 
•of  soda — 5  doses  being  given  in  twenty-four  hours.  To  older  patients 
from  3  to  4  grains  of  the  salicylate  may  be  given  at  a  dose — from  12  to 
24  grains  being  administered  in  twenty-four  hours.  Certain  children 
appear  to  be  predisposed  to  urticaria,  and  give  a  history  of  having  had 
several  attacks.  Those  who  suffer  from  persistent  intestinal  indigestion 
are  very  liable  to  recurrent  attacks,  which  are  sometimes  very  obstinate 
in  character.  Urticaria  due  to  the  ingestion  of  a  drug  will  disappear 
when  the  drug  is  withdrawn. 

The  management  of  the  cases  due  to  local  causes  demands  the  re- 
moval of  the  source  of  the  irritation  and  the  application  of  the  menthol 
ointment,  or  bathing  of  the  affected  part  with  a  1  per  cent,  carbolic 
acid  solution. 

RHUS  POISONING  (IVY  POISONING) 

Contact  with  the  Rhus  toxicodendron  produces  in  many  people  a 
most  active  dermatitis,  characterized  by  marked  burning  and  consider- 
a,ble  itching  of  the  involved  surface.  There  may  be  a  simple  erythema 
tut  usually  there  are  small  vesicles  and  bullse  filled  with  serum,  which, 
if  they  become  infected,  form  pustules,  with  the  possibility  of  multiple 
abscesses.  The  exposed  portions  of  the  body — the  hands,  arms,  face 
and  neck — are  the  most  frequently  affected  sites.  When  the  face  is 
involved,  great  disfigurement  may  result. 

Treatment. — I  have  used  various  measures  from  time  to  time  in  the 
treatment  of  this  form  of  dermatitis.  For  the  acute  stage — the  period 
of  itching,  burning,  and  edema — a  remedy  of  considerable  value  is  a 
wet  dressing  of  the  fluidextract  of  Grindelia  rohusta,  1  to  13^-^  drams  to 


572  THE    PRACTICE    OF    PEDIATRICS 

the  pint  of  water,  applied  on  lint  or  soft  old  linen.  The  solution  should 
be  used  cold  and  renewed  every  fifteen  to  thirty  minutes.  During  the 
stage  of  resolution  a  saturated  solution  of  boric  acid  may  be  used  in  the 
same  way,  or,  more  conveniently,  an  ointment  composed  of  5  per  cent, 
boric  acid  in  rose-water  ointment.  This  is  applied  to  the  parts  on  linen, 
after  which  resolution  usually  promptly  takes  place.  When  pustules 
develop,  they  must  be  opened  and  the  parts  treated  with  a  wet  dress- 
ing of  a  saturated  solution  of  boric  acid. 

A  solution  of  permanganate  of  potash,  1  :  2000,  is  a  most  satis- 
factory means  of  treatment.  The  involved  parts  are  freely  moistened 
with  the  solution  at  intervals  of  about  two  hours,  the  solution  mean- 
time being  allowed  to  dry  on  the  parts.  This  often  readily  controls 
the  acute  symptoms.  After  a  few  days  a  10  per  cent,  boric-acid  oint- 
ment may  be  used  to  soften  the  skin  and  remove  the  crusts  and  prod- 
ucts of  the  exudation. 

SCABIES  (ITCH) 

Scabies  is  a  contagious  disease  of  the  skin,  caused  by  the  burrowing 
of  the  female  itch-mite,  Acarus  scabiei. 

Location. — The  parts  selected  for  invasion  are  those  portions  of 
the  skin  which  are  least  protected  and  least  resistant,  the  favored  sites 
being  between  the  fingers  and  toes,  in  the  axilla,  and  in  the  groin.  The 
skin  over  the  trunk  is  usually  invaded  secondarily. 

,  The  impregnated  female  burrows  a  tunnel  into  the  layers  of  the  skin, 
which  serves  as  a  habitat  for  the  mite  during  her  life. 

In  the  burrow  or  canal  are  deposited  the  eggs,  larvge,  and  excre- 
tions of  the  acarus,  and  these  act  as  an  irritant,  producing  papules, 
vesicles,  and  skin  infiltration.  The  presence  of  the  parasite  and  its 
products  causes  intense  itching  which,  through  scratching,  indirectly 
adds  to  the  existing  skin  irritation.  If  the  skin  is  clean,  the  burrows 
may  be  seen  with  the  aid  of  a  magnifying  glass.  Upon  removal  of  the 
epidermis  at  the  end  of  the  canal  the  parasite  may  be  removed  with  a 
needle. 

Diagnosis. — Itching  is  intense  and  may  be  confined  to  the  skin  areas 
described,  or  involve  all  portions  of  the  skin  surface.  A  point  of  diag- 
nostic value  is  that  the  itching  is  much  worse  at  night  due  to  the  fact 
that  the  mite  evidently  becomes  more  active  as  a  result  of  the  increased 
warmth  and  quiet  supplied  by  the  unwilling  host. 

In  a  well-marked  case  as  a  result  of  the  action  of  the  acarus  together 
with  the  trauma  produced  by  scratching  there  is  a  complex  skin 
picture  very  difficult  to  describe.  An  eczema  with  all  its  possibilities 
of  skin  inflammation  and  infection  usually  supervenes.  The  burrows 
have  the  appearance  of  dark  colored  lines  extending  in  a  tortuous, 
zigzag  course  rarely  exceeding  )^^  inch  in  length,  and  these  are  usually 
visible  in  sufficient  number  to  make  the  diagnosis  positive. 

Treatment. — The  cases  differ  in  severity,  but  in  all  the  treat- 
ment is  practically  the  same,  varying  only  in  respect  to  the  necessity 
of  its  repetition  or  continuation.     At  bedtime  a  hot  bath  is  ordered, 


FURUNcuLOsis  (boils)  573 

from  105°F.  to  110°F.  While  in  the  bath  the  patient  is  vigorously 
scrubbed  with  a  towel  and  yellow  laundry  soap.  After  the  scrubbing 
he  is  dried  vigorously  and  sulphur  ointment,  U.  S.  P.,  rubbed  as 
vigorously  into  the  skin.  This  process  is  repeated  twice  at  intervals 
of  forty-eight  hours.  The  repetition  at  twenty-four-hour  intervals 
is  usually  too  irritating  to  the  skin.  The  third  treatment  usually  ter- 
minates the  case.  For  quite  young  children,  to  whom  the  sulphur 
ointment  may  be  too  irritating,  and  for  older  children  also  if  the  first 
application  produces  considerabe  dermatitis,  the  ointment  may  be 
diluted  one-fourth  or  one-half  by  the  addition  of  vaselin.  Care  must  be 
exercised  to  destroy,  boil,  or  otherwise  disinfect  all  clothing  previously 
worn  by  the  patient. 

FURUNCULOSIS  (BOILS) 

Boils  are  frequent  in  delicate,  poorly  nourished  infants  and  children, 
and  are  due  to  an  inoculation  of  the  deep  layers  of  the  skin  with  the 
staphylococcus.  Boils  may  develop  in  well  babies,  even  under  proper 
management,  for  many  delicate  skins  possess  a  very  poor  resistance  to 
the  staphylococcus.  Often  there  will  be  a  crop  or  two  comprising  per- 
haps not  over  five  or  six  lesions  in  all.  In  marasmic  infants  and  poorly 
nourished  young  children,  however,  the  lesions  may  occur  in  great 
number.  I  have  opened  over  one  hundred  furuncles  in  one  patient  in 
caring  for  the  successive  crops  as  they  appeared.  The  scalp  is  appar- 
ently the  most  fertile  field  for  their  development.  I  have  repeatedly 
seen  the  boils  coalesce,  forming  a  large,  sloughing  suppurating  mass. 
In  aggravated  cases,  in  delicate  infants  with  low  resistance,  fatal  results 
are  not  unusual  in  institutional  work.  What  might  be  looked  upon  as 
a  chronic  condition  of  furunculosis  sometimes  exists  in  older  children. 
The  boils  will  continue  to  appear  at  indefinite  intervals  for  a  year  or 
more  in  spite  of  active  vaccine  treatment. 

Treatment. — Local. — When  pus  is  evident  in  the  boil,  a  free  in- 
cision should  be  made  and  the  pus  expressed.  The  skin  about  the 
wound  should  be  washed  vigorously  with  tincture  of  green  soap  or 
ordinary  soap  and  water.  Applying  a  few  drops  of  a  solution  of 
bichlorid  of  mercury  is  of  little  or  no  value,  and  will  not  be  sufficient  to 
prevent  a  reinfection,  as  some  pus  invariably  escapes  upon  the  surround- 
ing healthy  skin  when  many  boils  are  opened.  A  wet  disinfectant 
dressing  or  a  disinfectant  ointment  should  follow  incision  and  cleans- 
ing. Bichlorid  dressings  are  to  be  used  only  temporarily  in  children. 
The  dressing  which  has  appeared  best  to  prevent  the  spread  of  the  in- 
fection when  the  involved  area  is  not  too  large  is  a  saturated  solution 
of  boric  acid,  applied  by  means  of  gauze  or  lint.  In  a  marantic  child, 
when  a  considerable  portion  of  the  surface  over  the  trunk  or  thorax 
needs  to  be  covered  the  repeated  renewal  of  the  solution  causes  a 
reduction  in  temperature  which  is  not  desirable.  In  treating  such 
infants,  and  in  out-patient  work  where  a  wet  dressing  cannot  be  used, 
an  ointment  of  15  per  cent,  boric  acid  in  vaselin  is  thickly  spread  on 
lint  and  applied  to  the  wound  and  a  considerable  portion  of  the  sur- 


574  THE    PRACTICE    OF    PEDIATRICS 

rounding  area.  The  dressing  should  be  changed  every  six  hours, 
Ichthyol  is  of  Httle  service  when  used  in  a  strength  of  less  than  20 
per  cent.  The  odor  is  disagreeable;  the  apphcation  stains  the  skin, 
and  the  clothing  and  controls  the  condition  no  better  than  does  the 
boric-acid  ointment.  Moreover,  the  latter  is  comparatively  inex- 
pensive. In  treating  fat  children  who  sometimes  develop  boils  on  the 
abraded  surfaces  at  the  folds  of  the  neck  or  the  nates,  and  children 
who  perspire  freely,  I  have  used  a  dusting-powder  composed  as  follows; 

I^     Pulv.  acidi  borici 5  j 

Pulv.  amyli, 

Pulv.  zinci  oxidi aa  S  iss 

M.  Sig. — Dusting-powder. 

This  is  appKed  as  soon  as  the  wound  is  closed,  and  the  parts  are 
thus  kept  dry. 

The  autogenous  vaccines  have  been  most  serviceable  in  the  treat- 
ment of  furunculosis  in  infants.     (See  Vaccine  Therapy,  p.  797.) 

Constitutional. — The  constitutional  treatment  is  important.  If  the 
child  is  marasmic  or  suffers  from  malnutrition,  the  general  treatment 
suggested  for  these  conditions  should  be  brought  into  use.  If  delicate 
or  anemic,  the  patient  should  have  the  advantage  of  the  suggestions 
on  p.  122.  In  the  many  cases  which  I  have  treated,  internal  medica- 
tion, other  than  that  directed  toward  the  improvement  of  the  general 
constitutional  condition,  has  been  without  value.  The  sulphid  of  cal- 
cium and  other  drugs  which  are  supposed  to  have  a  direct  influence 
upon  the  condition  have  proved  of  no  service.  They  were  not  consid- 
ered valueless  because  the  child  did  not  recover,  for  if  not  too  reduced 
in  vitality,  the  patient  always  recovers,  regardless  of  the  treatment. 
Observation  on  a  series  of  cases  of  this  type,  for  which  opportunity 
was  afforded  by  institution  work  has  shown  that  those  treated  with 
the  sulphid  of  calcium,  for  example,  made  no  greater  progress  than  did 
those  to  whom  it  was  not  given.  The  existence  of  this  line  of  treat- 
ment is  an  example  of  "heredity  in  medicine."  A  remedy  advocated 
by  some  one  of  consequence  in  the  past  is  handed  down  from  genera- 
tion to  generation  by  writers,  many  of  whom,  not  having  had  oppor- 
tunity to  support  their  advocacy  of  the  measure  with  observations  of 
value,  simply  repeat  what  has  been  said  by  their  predecessors. 

No  matter  how  extensive  the  process,  children  with  furunculosis 
may  be  bathed  as  in  health.  To  the  water  for  the  bath,  which  should 
first  be  boiled,  bicarbonate  of  soda,  one  tablespoonful  to  the  gallon,, 
should  be  added.     There  should  be  little  or  no  friction  of  the  skin. 

PEDICULI  (HEAD  LICE) 

Head  lice,  pediculi  capitis,  constitute  a  very  frequent  source  of 
annoyance  in  out-patient  and  hospital  work  among  children.  Occa- 
sionally children  better  situated  may  become  infected  in  school  or  in 
public  conveyances  and  carry  the  vermin  to  other  members  of  the 
family.  I  have  repeatedly  known  all  the  female  members  of  a  house- 
hold to  become  infected. 


TINEA    CIRCINATA    (rING-WORM)  575 

Symptoms. — As  a  result  of  the  irritation  produced  by  the  insect 
and  the  enforced  scratching,  an  eczema  of  the  scalp  is  of  frequent  oc- 
currence. The  eczema  may  be  slight  or  give  rise  to  a  most  extensive 
and  disgusting  condition.  The  suppurating  scalp,  matted  with  pus, 
crusts,  nits,  and  vermin,  supplies  a  picture  disagreeable  even  to  consider. 
In  not  a  few  instances  I  have  seen  the  brows  and  eyelashes  involved. 
A  slight  degree  of  postcervical  adenitis  is  the  rule  in  cases  of  some 
weeks'  duration. 

Diagnosis. — The  diagnosis  does  not  depend  upon  finding  the  live 
vermin.  The  louse  cements  its  egg  to  the  hair,  and  the  presence  of 
the  '*nit"  is  in  itself  diagnostic. 

Treatment. — The  most  successful  and  cleanly  treatment  consists  in 
cutting  the  hair  short.  The  head  should  then  be  washed  with  soap 
and  water  twice  a  day;  and  once  daily  after  the  drying,  the  scalp  should 
be  thoroughly  moistened  with  the  following  solution : 

I^     Acidi  acetici 3ij 

^Etheris  sulphuric! 5iij 

Tincturse  delphinii, 

Spirit!  vini  rectificati aa  5  iv 

Improvement  will  follow  a  few  treatments.  The  pediculi  will  be 
killed  and  the  nits  may  be  removed  with  a  fine-tooth  comb.  If  the 
patient  is  a  girl,  it  is  not  absolutely  necessary  to  sacrifice  the  hair.  It 
may  be  parted  from  various  portions  of  the  scalp  and  the  solution  ap- 
plied, without  the  previous  washing.  However,  if  the  hair  is  not  cut, 
a  much  longer  time  willl  be  required  to  effect  a  cure. 

TINEA  CIRCINATA  (RING-WORM) 

Tinea  circinata,  ring-worm  of  the  body,  is  a  highly  contagious  para- 
sitic skin  infection. 

Etiology. — The  disease  is  due  to  the  trichophyton  fungus,  which  is 
identical  with  that  causing  tinea  tonsurans.  The  exposed  skin  surface, 
the  neck,  and  hands  are  the  sites  most  frequently  involved. 

Domestic  animals  are  subject  to  the  disease.  It  is  rare  in  cows  and 
horses,  but  quite  common  in  dogs  and  cats.  Children  are  often  in- 
fected from  cats  and  dogs. 

Symptoms. — The  disease  usually  makes  its  appearance  in  the  form 
of  a  small,  reddened,  irregular-shaped  area,  which  soon  becomes  circu- 
lar and  is  covered  with  a  fine,  scaly  desquamation.  The  area  is  sharply 
defined  and  spreads  through  the  development  of  fine  papules  around 
the  border  of  the  patch.  As  the  process  extends  there  is  a  paling  and 
smoothing  out  of  the  surface  in  the  middle  of  the  patches,  while  the 
exterior  border  remains  somewhat  elevated  and  reddened.  This  pro- 
duces in  the  lesion  a  ring-form  appearance  which  has  given  rise  to  the 
term  by  which  it  is  known.  There  may  be  but  one  lesion  or  there  may 
be  dozens  of  varying  sizes,  3^  inch  to  2  or  more  inches  in  diameter. 
Occasionally  the  smaller  patches  run  together,  forming  large  areas  of 
irregular  shape. 

Diagnosis. — The  diagnosis  is  usually  not  difficult.     The  character- 


576  THE    PRACTICE    OF    PEDIATRICS 

istic  well-defined  ring,  circumscribed  and  usually  multiple,  is  not  simu- 
lated by  other  skin  diseases.  In  some  cases  in  which  the  margin  is 
not  so  well  defined,  and  in  those  which  show  one  or  more  circumscribed 
scaly  areas,  the  lesion  may  be  confused  with  a  patch  of  seborrheic 
eczema.  Psoriasis  may  resemble  ring-worm.  Psoriasis  is,  however, 
very  rare  in  children.  Furthermore  the  lesions  of  psoriasis  are  usually 
located  and  grouped  on  the  extensor  surfaces  and  at  the  margin  of  the 
hair,  and  the  scales  are  thicker  and  more  abundant  than  those  of  ring- 
worm. In  patches  of  acute  eczema  the  characteristic  abrupt  margin 
is  absent,  itching  is  more  marked  than  in  ring-worm,  and  the  inflam- 
matory manifestations  are  changeable  from  day  to  day,  while  in  ring- 
worm the  appearance  of  the  lesion  is  without  change.  If  doubt  exists 
and  the  latter  condition  is  present,  a  microscopic  examination  of  the 
scales  to  which  a  few  drops  of  liquor  potassii  have  been  added  will  re- 
veal the  presence  of  the  long,  delicate  threads  of  mycelium  and  thus 
settle  the  diagnosis. 

Treatment.^ — The  treatment  consists  in  the  use  of  some  irritant 
that  will  produce  a  desquamation  of  the  superficial  layers  of  the  skin 
in  which  the  fungus  is  located.  The  tincture  of  iodin  has  proved  a 
satisfactory  remedy  whenever  the  lesion  is  located  where  its  use  is  pos- 
sible. Two  or  three  applications  of  the  U.  S.  P.  tincture  at  twenty- 
four-hour  intervals  constitute  all  the  treatment  ordinarily  required. 
If  the  case  proves  obstinate,  2  grains  of  the  bichlorid  of  mercury  may 
be  added  to  each  ounce  of  tincture  of  iodin.  If  the  lesion  is  situated 
on  the  face  or  elsewhere  on  the  exposed  surface  of  the  body,  5  grains 
of  bichlorid  of  mercury  may  be  dissolved  in  equal  parts  of  alcohol  and 
glycerin,  one  ounce  each,  and  applied  locally  three  or  four  times  daily 
until  a  slight  dermatitis  results.     A  rapid  cure  follows  this  treatment. 

TINEA  TONSURANS  (RING- WORM  OF  THE  SCALP) 

Ring-worm  of  the  scalp  is  of  frequent  occurrence  in  institutions  for 
children,  and  is  greatly  dreaded  because,  when  once  it  gets  a  foothold, 
it  is  most  difficult  to  eradicate.  In  one  epidemic  of  which  I  had  charge 
there  were  over  100  cases.  These  cases  were  all  cared  for  by  nurses 
and  orderlies  who  lived  in  the  wards  with  the  children  and  not  one 
case  occurred  in  an  adult.  The  susceptible  age  appears  to  be  from  the 
third  to  the  tenth  year. 

Etiology. — Ping-worm  is  due  to  the  action  of  the  trichophyton  fun- 
gus. The  disease,  which  is  most  contagious,  is  transmitted  by  ex- 
change of  caps,  by  means  of  towels,  brushes,  combs,  etc.  The  dis- 
eased hair,  according  to  Crocker,  when  placed  under  the  microscope, 
after  being  soaked  in  B.  P.  liquor  potasses  for  half  an  hour  and  gently 
pressed  out  under  the  cover-glass,  presents  the  following  appearance: 
The  hair  may  be  seen  bent  like  a  green  stick,  while  the  free  end  is  frayed 
out  like  a  brush,  and  (with  a  power  of  at  least  200  or  300  diameters) 
abundant  conidia  or  spores,  with  scanty  mycelium,  may  be  seen  to 
permeate  the  shaft,  both  downward  to  the  root  end  and  upward  above 
the  surface  for  some  distance,  this  appearance  differentiating  the  con- 


TINEA    TONSURANS  577 

dition  from  favus.  Between  the  inner  root-sheath  and  the  shaft  the 
conidia  are  also  apparent  in  great  numbers,  but  the  mycehum  is  less 
abundant  in  the  hairs  than  in  the  scales.  The  conidia  measure  from 
4  to  5  micra,  and  are  round  and  sharply  contoured,  with  a  central 
nucleus  like  a  black  dot.  The  mycelium  consists  of  well-defined,  trans- 
parent, branched  and  pointed  threads,  terminating  in  conidia.  They 
may  be  seen  best  in  the  shaft  near  the  bulb  or  between  and  on  the 
scales. 

Diagnosis. — The  diagnosis  is  not  difficult.  The  circular  circum- 
scribed patch  with  the  short  ''stubbles"  of  hairs  on  the  otherwise, 
normal  scalp  is  simulated  by  no  other  condition.  The  diameter  of 
the  involved  area  varies  from  3^^  inch  to  two  or  three  inches.  A  large 
denuded  area  is  usually  the  result  of  the  coalescing  of  smaller  areas. 
There  may  be  but  one  involved  area  on  a  scale  and  there  may  be  a 
dozen. 

Prophylaxis. — To  prevent  an  epidemic  when  the  disease  breaks  out 
in  an  institution  which  is  the  permanent  home  of  children  is  most 
necessary  and  yet  most  difficult.  The  only  means  of  stopping  the 
spread  of  the  disease,  in  my  experience,  has  been  in  having  the  heads 
of  all  the  unaffected  children  closely  clipped  and  giving  them  a  shampoo 
of  equal  parts  of  kerosene  and  olive  oil  twice  weekly. 

Treatment. — Cures  are  diflacult,  and  the  treatment  must  be  along 
radical  lines.  In  an  epidemic  several  years  ago  at  the  Country  Branch 
of  the  New  York  Infant  Asylum,  abundant  opportunity  was  offered 
to  test  the  various  measures  of  treatment  advocated  by  different  ob- 
servers. Among  the  applications  used  were  chrysarobin  in  various 
combinations,  carbolic  acid,  iodin,  bichlorid  of  mercury,  sulphur,  and 
white  precipitate. 

The  location  of  the  fungus  in  the  hair-follicle  renders  it  very  diffi- 
cult to  apply  any  drug  so  that  it  will  be  effective  as  a  parasiticide.  In 
order  to  accomplish  this  it  is  absolutely  necessary  to  cut  the  hair  of 
the  entire  scalp  as  short  as  possible.  Upon  beginning  the  treatment 
the  scalp  is  thoroughly  scrubbed  with  water  and  strongly  alkahne 
yellow  laundry  soap,  so  as  to  remove  all  the  dead  hair  and  desquamated 
epithehum.  The  parasiticide  to  be  used  is  then  rubbed  into  the  dis- 
eased area  and  for  a  considerable  distance  over  the  surrounding  healthy 
scalp.  The  parasiticide  which  proved  most  valuable  to  us  was  com- 
posed of  bichlorid  of  mercury,  2  grains  in  3^^  ounce  each  of  olive  oil 
and  kerosene.  The  bichlorid  must  be  dissolved  in  a  small  quantity  of 
alcohol  before  it  is  added  to  the  oil  mixture.  This  is  rubbed  into  the 
diseased  area  every  day  until  the  scalp  becomes  sore  and  tender.  In 
order  to  prevent  the  spread  of  the  infection  to  other  parts,  the  kerosene 
and  olive  oil  without  the  bichlorid  may  be  applied  every  fourth  day, 
without  friction,  to  the  entire  scalp.  To  effect  a  prompt  cure  it  is 
necessary  to  produce  a  dermatitis  at  the  site  of  the  lesion.  When  this 
occurs,  the  treatment  is  temporarily  discontinued.  As  soon,  however, 
as  the  dermatitis  subsides  another  inflammation  is  produced  in  like 
manner.  After  three  or  four  weeks  this  treatment  may  be  discon- 
37 


578  THE    PRACTICE    OE    PEDIATRICS 

tinued  while  the  patient  is  still  kept  under  observation,  in  order  that 
the  physician  may  confirm  the  results.  A  daily  application  of  sterile 
oil  aids  in  bringing  the  skin  to  a  normal  condition. 

In  treating  one-third  of  the  children  in  the  epidemic  referred  to, 
2  grains  of  the  bichlorid  of  mercury  were  added  to  1  ounce  of  the  tinc- 
ture of  iodin.  Twenty-six  cases  were  treated  by  this  method,  with  an 
average  duration  of  treatment  of  eight  and  one-half  weeks.  Several 
recovered -in  four  weeks,  while  for  others  twelve  weeks  of  treatment 
were  necessary.-  So  long  as  the  treatment  is  in  progress  the  child  should 
wear  a  cap,  day  and  night.  This  may  be  made  of  any  cheap,  light- 
weight material,  which,  after  a  day  or  two  of  use,  may  be  burned.  In 
our  cases  cheese-cloth  caps  were  used.  Rubber  gloves  were  necessary 
to  protect  the  hands  of  the  nurse  who  made  the  applications,  especially 
if  there  were  many  heads  to  be  treated. 

In  this  epidemic,  which  was  controlled  by  the  above  means, 
prophylaxis  was  obtained  by  the  use  of  the  kerosene  and  olive  oil  with- 
out the  bichlorid.  It  was  found  impossible  to  maintain  a  quarantine 
permanently  or  effectually  even  for  a  short  time,  particularly  during 
the  warmer  months.  Therefore  every  inmate  of  the  asylum  of  the 
"runabout"  age  who  did  not  have  the  disease  was  treated  as  an  in- 
cipient case.  Every  head  was  "clipped"  and  the  hair  kept  short. 
Twice  a  week  the  children  were  given  a  kerosene  and  olive  oil 
shampoo. 

In  private  work  the  continued  use  of  kerosene  and  olive  oil  is  not 
popular,  for  reasons  readily  understood.  In  such  cases  the  hair  should 
be  clipped  as  soon  as  the  case  is  diagnosed,  and  a  kerosene  shampoo 
given.  The  bichlorid  of  mercury,  2  grains  to  1  ounce  of  tincture  of 
iodin,  U.  S.  P.,  should  be  applied  to  the  parts  with  sufficient  vigor  to 
produce  a  dermatitis.  If  the  disease  shows  a  tendency  to  spread  be- 
yond the  original  site,  it  is  best  prevented  by  the  use  of  the  kerosene 
and  oHve  oil,  in  the  manner  above  described.  Bulkley*  claims  that  all 
cases  are  cured  spontaneously  at  puberty  as  practically  no  cases  are 
seen  in  the  scalp  of  the  adult. 

Stricklerf  reports  favorably  on  the  results  of  20  cases  of  ring-worm 
of  the  scalp  treated  by  vaccines. 

Roentgen-ray  Treatment  of  Ring-worm  of  the  Scalp. — With  many 
improvements  in  technic  and  apparatus  a;-ray  treatment  is  now  com- 
paratively without  danger  and  offers  a  very  speedy  cure.  The  treat- 
ment must  be  in  the  hands  of  experts. 

The  efficacy  of  the  treatment  is  due  to  the  falling  out  of  the  infected 
hairs  carrying  with  them  the  organisms.  There  is  no  direct  action  of 
the  parasite  so  that  precautions  must  be  observed  after  treatment  to 
prevent  the  infection  of  others  by  the  falling  hair.  This  is  easily  ac- 
complished by  keeping  the  head  covered.  About  seven  days  after 
a;-ray  treatment  a  local  erythema  develops,  lasting  three  to  four  days. 
The  hair  falls'out  about  the  end  of  three  weeks  and  begins  to  re-grow 

♦Journal  A.  M.  A.,  July  17,  1915. 
t  Journal  A.  M.  A.,  Aug.  17,  1912. 


PEMPHIGUS    NEONATORUM  579 

in  three  months.  No  local  treatment  is  used  two  weeks  prior  to  treat- 
ment and  for  one  month  afterward  when  a  5  per  cent,  ointment  of 
sulphur  or  of  ammoniated  mercury  U.  S.  P.  is  applied.  (For  com- 
plete details  of  technic  consult  Mackie  and  Remer,  Medical  Record, 
N.  Y.,  Vol.  LXXVIII,  p.  217.) 

IMPETIGO  CONTAGIOSA 

Impetigo  contagiosa,  as  the  name  implies,  is  a  contagious  disease 
of  the  skin.  Several  children  in  the  same  family  or  school  often  have 
the  infection  at  the  same  time.  I  have  known  one  school-child  to 
infect  an  entire  class  of  20.  Cases  of  impetigo  are  seen  almost  ^daily 
in  large  out-patient  clinics  for  children.  The  exposed  parts  comprising 
the  face,  head,  and  hands  are  those  most  frequently  involved. 

Etiology. — Bacteriologic  examination  shows  a  mixed  infection  with 
staphylococcus  predominating. 

Symptoms. — At  first  the  lesion  consists  of  a  few  closely  grouped 
vesicles,  which  rapidly  develop  into  pustules.  These  shortly  form  a 
dry  crust  of  variable  size  and  thickness.  One  area  or  a  dozen  or  more 
may  be  involved.  Several  small  lesions  may  coalesce,  forming  one 
large  lesion.  I  have  seen  the  crusts  two  inches  in  diameter.  They 
rest  upon  an  inflamed  base,  which  bleeds  slightly  when  they  are  re- 
moved. There  are  no  constitutional  symptoms,  and  rarely  is  there 
itching.  The  only  evidence  of  the  disease  is  the  disfigurement  occa- 
sioned by  the  dry,  adherent  crusts. 

Treatment. — The  most  satisfactory  procedure  has  been  to  soften 
the  crusts  by  the  application  of  gauze  saturated  with  sterilized  olive 
oil,  the  gauze  being  bound  to  the  parts.  Usually  in  twenty-four  hours 
the  crusts  may  readily  be  removed.  Afterward  an  ointment  of  10  per 
cent,  boric  acid  in  ointment  of  rose-water,  or  one  composed  of  10  per 
cent,  ichthyol  in  vaselin,  should  be  spread  on  sterile  gauze  and  bound 
to  the  suppurating  surface.  The  dressing  should  be  changed  at  least 
night  and  morning.  Recovery  is  usually  complete  in  from  two  to 
three  days.  When  the  crusts  are  on  the  lip  or  other  portions  of  the 
face  where  the  dressing  described  cannot  readily  be  applied,  the  lesions 
should  be  kept  moist  with  either  the  boric  acid  or  ichthyol  ointment. 
If  the  gauze  is  not  used,  fresh  ointment  should  be  applied  at  least  every 
three  hours,  both  before  and  after  the  crusts  are  removed. 

PEMPHIGUS  NEONATORUM 

Pemphigus  in  the  newly  born  is  an  infection  of  the  skin  manifesting 
itself  in  a  bullous  eruption,  which  may  appear  on  any  portion  of  the 
surface.  There  have  been  two  epidemics  of  pemphigus  at  the  New 
York  Infant  Asylum,  involving  in  all  about  30  cases.  The  patients 
were  mostly  well-nourished  infants.  The  origin  of  the  disease  in  each 
epidemic  was  unknown.  From  a  few  hours  to  a  day  after  birth  the 
bullae  of  the  seropus  appeared,  and  in  several  cases  the  process  was  so 
extensive  through  their  coalescence  that  large  portions  of  the  skin  sur- 
face were  denuded  when  the  bullae  ruptured.     The  disease  is  very  con- 


580  THE    PRACTICE    OF    PEDIATRICS 

tagious,  and  these  epidemics  were  only  stayed  by  rigid  quarantine  of 
all  the  newly  born  and  by  closing  the  operating  room.  Examination 
of  the  serum  from  the  bullae  of  several  cases  showed  the  Staphylococcus 
albus.     The  mortahty  was  about  20  per  cent. 

Treatment. — The  management  of  the  first  epidemic  consisted  in 
opening  the  blebs  and  in  the  application  of  various  antiseptic  solutions 
and  ointments.  Not  much  improvement  followed  until  creolin  baths 
were  used.  This  treatment  not  only  relieved  those  cases  which  had 
developed,  but  the  systematic  bathing  in  a  1  per  cent,  creolin  solution 
of  all  the  newly  born  in  the  institution  apparently  prevented  the  spread 
of  the  infection. 

During  the  second  epidemic  the  house  physician,  Dr.  Carswell,  be- 
lieves that  favorable  results  were  obtained  with  a  30  per  cent,  solution 
of  ichthyol  kept  applied  to  the  parts  and  changed  three  times  a  day. 

ERYTHEMA  NODOSUM 

Erythema  nodosum  is  characterized  by  the  formation,  in  the  skin 
and  connective  tissue,  of  multiple  brownish  nodules  of  varying  size. 

Location  of  the  Lesion. — The  nodules  are  most  frequently  seen  over 
the  anterior  surface  of  the  leg. 

Etiology. — I  look  upon  the  disease  as  an  infection — one  of  the  many 
protean  manifestations  of  rheumatism.  In  my  cases  endocarditis  has 
not  been  a  complication.  All  my  cases  have  been  in  rheumatic  sub- 
jects, and  associated  with  peliosis  rheumatica. 

Symptoms. — Previous  to  the  appearance  of  the  nodules,  there  may 
be  fever  and  loss  of  appetite  and  general  indisposition  on  the  part  of 
the  child.  According  to  my  observation  these  prodromal  symptoms 
have,  however,  been  unusual,  the  local  manifestations  constituting 
prominent  symptoms,  and  in  some  cases  the  only  evidence  of  the  dis- 
ease. The  nodes  are  very  painful  to  the  touch,  and  show  a  black  and 
blue  discoloration.  The  entire  anterior  surface  of  the  tibia  may  have  a 
bronzed  appearance. 

Pigmentation  follows  the  disappearance  of  the  nodules. 

In  mild  cases  the  pain  is  confined  to  the  lesions.  In  severe  attacks 
there  is  not  only  fever,  as  already  mentioned,  but  also  a  great  deal  of 
joint  pain  and  muscle  soreness. 

Treatment. — If  there  is  fever,  the  patient  should  be  kept  in  bed 
until  the  acute  febrile  period  is  passed  and  the  nodules  begin  to  dis- 
appear. The  treatment  is  begun  with  the  administration  of  one  or  two 
grains  of  calomel,  followed  by  a  saline  laxative. 

Milk  and  a  vegetable  diet  are  prescribed.  A  very  small  amount 
only  of  sugar  is  permissible.  As  a  rule,  my  best  results  from  drug 
therapy  have  been  gained  by  the  use  of  5  grains  of  the  salicylate  of 
soda  (wintergreen)  in  combination  with  10  grains  of  sodium  bicarbon- 
ate in  6  ounces  of  water  after  meals. 

Illustrative  Case. — A  delicate  girl  had  three  crops  of  nodules,  the  different  crops 
having  appeared  at  intervals  of  about  three  months.  The  first  attack  was  asso- 
ciated with  peliosis  and  urticaria.  The  treatment  which  I  had  employed  success- 
fully previous  to  this  case  consisted  of  the  use  of  the  salicylate  and  bicarbonate  of 


ERYSIPELAS  581 

soda.  This  patient,  who  is  markedly  rheumatic,  had  taken  large  quantities  of  the 
salicylate,  and  its  readministration  had  no  effect;  but  in  all  three  attacks  the  nodules 
began  to  diminish  and  disappeared  completely  under  the  administration  of  30 
grains  of  iodid  of  potash. 

The  duration  of  my  cases  has  been  from  ten  days  to  three  weeks, 
with  the  exception  of  the  one  referred  to,  which  persisted  for  six  weeks, 
until  the  iodid  was  brought  into  use,  when  the  improvement  was 
prompt. 

Local  Measures. — The  most  satisfactory  local  application  for  the 
relief  of  pain  is  the  lead  and  opium  solution,  U.  S.  P.,  applied  warm  to 
the  parts  by  means  of  soft  old  linen  or  gauze,  over  which  oiled  silk  or 
rubber  tissue  is  placed,  to  prevent  too  rapid  evaporation,  the  entire 
dressing  being  held  in  position  by  bandages. 

ERYTHEMA  MULTIFORME 

As  its  name  indicates,  this  is  a  disease  of  the  skin  manifesting  itself 
in  many  different  forms. 

Etiology. — It  is  most  frequently  encountered  in  ill-conditioned 
children  of  rheumatic  inheritance,  and  is  frequently  associated  with  dis- 
orders of  digestion. 

Symptomatology. — The  disease  usually  manifests  itself  in  reddened 
papules,  macules,  and  erythematous,  infiltrated  skin  areas,  all  of  which 
are  most  frequently  found  over  the  dorsal  surfaces.  There  is  no  pain 
and  but  little  if  any  itching. 

Diagnosis. — The  condition  is  to  be  differentiated  from  acute  urti- 
caria by  the  fact  that  in  urticaria  the  lesions  are  very  transient,  appear- 
ing and  disappearing  rapidly,  while  in  erythema  multiforme  several  days 
are  required  for  resolution  to  take  place. 

Treatment. — The  management  consists  in  relieving  whatever  diges- 
tive derangement  may  exist  by  the  use  of  calomel,  rhubarb  and  soda, 
and  the  enforcement  of  a  suitable  diet  (p.  102). 

For  a  child  five  years  of  age  3  grains  of  salicylate  of  soda  with  6 
grains  bicarbonate  of  soda  in  4  ounces  of  water  should  be  given  after 
meals  three  times  daily.  In  the  event  of  itching,  which  is  unusual,  an 
ointment  composed  of  10  grains  of  menthol  in  1  ounce  of  rose-water 
ointment  will  usually  furnish  relief.  The  eruption  seldom  lasts  longer 
than  a  week.     A  pigmented  area  may  remain  at  the  site  of  the  lesion. 

ERYSIPELAS 

Erysipelas  is  a  serofibrinous  inflammation  of  the  skin,  and  may  go 
on  to  the  stage  of  gangrene.  It  is  caused  by  the  streptococcus,  which 
enters  through  a  wound  or  abrasion  and  spreads  along  the  lymph- 
channels.  Strains  of  streptococcus  isolated  from  the  lesion  of  erysipelas 
cannot  be  differentiated  by  any  known  test  from  other  strains  isolated 
from  a  case  of  scarlet  fever  or  from  a  suppurating  focus  anywhere  in 
the  body. 

In  newly  born  infants  the  umbilicus  may  be  the  point  of  entrance  for 
the  streptococcus,  and  erysipelas  of  the  surrounding  portions  of  the 
body-wall  may  result. 


582  THE    PRACTICE    OF    PEDIATRICS 

Etiology. — Infants  with  low  resistance  are  predisposed.  Thus  a 
majority  of  my  cases  were  seen  in  the  New  York  Nursery  and  Child's 
Hospital.  Nevertheless,  babies  ideally  cared  for  are  sometimes  victims 
of  the  infection.  The  absence  of  resistance  of  the  young  to  bacterial 
invasion  is  unquestionably  a  factor  in  determining  the  age  incidence. 

Mode  of  entrance:  In  the  newly  born  the  streptococcus  may  enter 
the  skin  by  the  nasal  route,  or  the  navel  may  be  the  seat  of  the  initial 
infection.  Later  in  development  the  process  may  begin  in  any  portion 
of  the  skin  surface.     The  scalp  perhaps  is  the  favorite  site. 

Symptoms. — The  first  sign  may  be  fever,  the  cause  of  which  is  not 
known  until  a  reddened,  indurated  area  with  sharply  defined  border  is 
found  at  some  point  in  the  body.  The  infection,  when  not  very  severe, 
may  invade  the  scalp  and  continue  to  spread  unrecognized  because  of 
the  protection  of  the  hair.  Usually  a  considerable  area,  at  least  two  or 
three  inches  in  diameter,  will  be  present  when  the  disease  is  discovered. 
From  this  primary  area  there  is  a  slow  progressive  spreading  of  the  pro- 
cess, the  margins  of  the  affected  zone  remaining  sharply  defined.  The 
inflammation  may  be  arrested  at  any  point  or  it  may  involve  the  entire 
body.  The  slowly  creeping  red  line  of  demarcation  at  all  times  sharply 
defines  the  normal  skin  from  the  reddened  infected  skin  and  subcu- 
taneous tissue.  The  portions  involved  swell  to  two  or  three  times  the 
normal  size.  The  skin  over  the  feet  and  hands  may  be  swollen  almost 
to  the  point  of  rupture.  Severe  infections  are  never  followed  by  re- 
covery. If  the  case  is  mild,  the  general  process  will  be  less  intense,  the 
creeping  extension  less  rapid,  and  the  response  to  treatment  more 
prompt,  permitting  recovery. 

The  temperature  is  very  high — usually  104''  to  106°r, — with  but 
little  variation.  The  height  of  the  temperature  is  indicative  of  the 
severity  of  the  infection.     In  mild  infections  only  the  fever  may  be  slight. 

With  erysipelas  the  child  is  very  uncomfortable  and  restless  and  cries 
much,  giving  evidence  of  considerable  pain,  particularly  upon  manipu- 
lation. 

Complications. — Erysipelas  does  not  predispose  to  any  particular 
form  of  illness.  Patients  who  resist  the  infection  may  develop  broncho- 
pneumonia as  a  terminal  complication. 

More  often  the  digestive  system  becomes  involved,  the  child  loses 
weight  rapidly,  and  dies  from  exhaustion. 

A  complicating  meningitis  is  not  an  infrequent  cause  of  death. 

Prognosis. — Erysipelas  is  a  particularly  fatal  disease  in  infants. 
In  the  new-born,  95  per  cent,  of  the  cases  are  fatal.  Fifty  per  cent,  of 
my  cases  occurring  in  children  under  one  year  of  age  have  been  fatal. 
When  the  streptococcus  of  erysipelas  gains  entrance  into  the  skin  of  an 
infant,  it  is  unusual  for  the  entire  skin  surface  not  to  become  involved 
before  the  process  subsides.  The  long-continued  high  temperature, 
the  toxemia,  the  discomfort  from  the  inflammation,  and  the  interfer- 
ence with  nutrition  so  greatly  reduce  the  patient  that  even  if  the  disease 
is  resisted  during  the  acute  stage  the  subject  is  very  apt  to  die  later  from 
exhaustion. 


ERYSIPELAS  583 

This  was  the  outcome  in  four  cases  recently  at  the  New  York  Infant  Asylum, 
where  each  child  went  through  the  active  period  of  the  disease,  but  died  a  week  or 
two  afterward  from  exhaustion  and  marasmus. 

Treatment. — The  treatment  is  unsatisfactory,  particularly  so  in 
young  children.  The  younger  the  child,  the  graver  the  prognosis. 
Absolutely  nothing  is  to  be  promised.  I  have  employed  scarifications 
in  advance  of  the  line  of  the  slowly  creeping  inflammation,  and  whether 
solutions  of  the  bichlorid  of  mercury,  carbolic  acid,  or  ichthyol  were 
used  as  a  dressing,  I  have  seen  the  red  line  pass  the  scarified,  disinfected 
surface,  regardless  of  the  nature  of  the  anticeptic  and  regardless  of  the 
vigor  and  vitality  of  the  child. 

The  termination  of  the  case,  whether  in  recovery  or  death,  depends 
to  a  great  extent  upon  the  resistance  of  the  patient  and  the  severity  of 
the  infection,  so  that  our  first  step  should  be  to  place  the  child  in  the 
best  position  to  resist  the  disease. 

General  Measures. — Perhaps  the  most  important  factor  in  the  treat- 
ment is  abundance  of  fresh  air.  In  the  winter  the  child  does  best  in  a 
room  with  windows  wide  open,  not  for  a  few  moments  at  intervals,  but 
continuously.  Protection  with  hot-water  bags  and  sufficient  clothing 
eliminates  danger,  as  long  as  the  temperature  of  the  room  does  not  fall 
below  55°F.  At  other  seasons  of  the  year  the  patient  should,  if  pos- 
sible, be  kept  out-of-doors. 

Infants  with  erysipelas  are  particularly  liable  to  develop  gastro- 
enteric disorders.  In  case  the  child  is  bottle-fed,  the  milk  mixture 
should  at  once  be  reduced  from  50  to  75  per  cent,  below  the  normal  by 
the  addition  of  barley-water  or  granum-water  No.  1,  so  that  the 
amount  of  fluid  given  at  a  feeding  remains  unchanged. 

Internal  medication,  such  as  I  have  used,  has  been  of  no  value  unless 
stimulating  or  sustaining  in  nature.  The  tincture  of  the  muriate  of 
iron  is  not  to  be  given  young  infants  with  erysipelas,  for  it  almost  invari- 
ably disturbs  the  appetite  and  interferes  with  the  digestion. 

In  the  event  of  high  temperature — above  104°F. — the  cool  pack 
(p.  777)  may  be  found  effective. 

Local  Applications. — The  local  agent  which  is  unquestionably  of 
some  value  is  ichthyol.  I  prefer  a  30  per  cent,  solution  if  the  involved 
area  is  on  one  or  more  of  the  extremities  or  a  small  portion  of  the  trunk. 
Solutions  as  dressings  should  not  be  used  for  infants  when  the  erysipe- 
latous process  involves  the  face  or  much  of  the  trunk.  When  these 
parts  are  involved,  a  dressing  of  30  per  cent,  ichthyol  ointment  in  vaselin 
should  be  applied  on  strips  of  lint  or  linen  and  renewed  every  three 
hours.  The  frequent  renewal  is  important,  and  the  ointment-dressing 
should  be  used  only  on  the  acutely  involved  areas.  When,  in  a  given 
case,  the  inflammation  begins  to  subside,  the  dressings  should  be  re- 
moved and  the  parts  bathed  freely.  In  this  connection  it  must  be  re- 
membered that  the  skin  is  an  important  organ  of  excretion,  particularly 
of  carbon  dioxid.  The  constant  covering  of  comparatively  large  sur- 
faces on  a  small  body,  by  interfering  with  the  function  of  the  skin,  may 
become  a  serious  matter.     The  local  treatment  with  ichthyol  should 


584  THE    PRACTICE    OF    PEDIATRICS 

follow  up  the  extension  of  the  inflammatory  process  and  be  continued 
until  it  subsides.  Of  later  years  I  have  been  using  with  a  fair  degree  of 
success,  a  wet  dressing  of  a  saturated  solution  of  boracic  acid.  The 
lotion  is  applied  on  old  linen  or  several  thicknesses  of  gauze.  The  parts 
are  kept  continually  wet  with  the  solution  day  and  night. 

Stimulants. — Nearly  every  infant  with  erysipelas  will  require  stimu- 
lation. For  this  purpose  small  doses  of  whisky  well  diluted  appear  best. 
From  5  to  15  drops  at  two-hour  intervals  for  children  under  two  years 
of  age  has  aided  me,  I  am  sure,  in  carrying  the  patients  through  to  a 
successful  convalescence.  Erysipelas  is  the  only  disease  in  which  it  is 
wise  to  use  alcohol  early,  and  in  many  instances  as  the  only  stimulant. 

Convalescence. — When  the  inflammation  subsides,  the  child  is  by  no 
means  to  be  regarded  as  well;  for  even  in  the  absence  of  sequelae,  such 
as  a  phlegmon,  endocarditis,  or  nephritis,  vitality  may  have  become  so 
reduced  that  sudden  death  may  take  place  when  it  is  thought  the  pa- 
tient is  well  on  the  road  to  recovery,  such  a  result  being  due,  perhaps, 
to  an  unrecognized .  myocarditis.  During  the  entire  attack  and 
throughout  convalescence  the  child  should  be  fed  to  the  limit  of  diges- 
tive capacity,  but  never  beyond  this  limit.  Correct  feeding  is  possible 
only  by  careful  observation  of  the  case  and  frequent  inspection  of  the 
stools. 

Vaccine  Therapy. — The  value  of  vaccine  therapy  in  this  disease 
remains  to  be  proved.     (See  p.  797.) 

ECZEMA 

In  the  consideration  of  eczema  we  are  dealing  with  a  disease  which  is 
very  frequently  encountered  in  infants.  If  we  group  together  all  the 
skin  diseases  of  infancy  and  childhood,  it  will  be  found  that  eczema 
considerably  exceeds  in  prevalence  all  the  others  combined.  This  is 
not  surprising  when  we  remember  the  exposed  situation  of  the  skin,  its 
delicate  structure,  and  its  manifold  functions  of  absorption,  secretion, 
excretion,  and  heat  radiation. 

Etiology. — Grossly,  eczema  as  it  occurs  in  infants  may  be  divided 
into  two  types;  the  first,  due  to  causes  operating  from  without  the 
body,  including  local  infection  of  various  kinds  or  local  irritation  of 
whatever  nature;  the  second,  due  to  abnormal  systemic  conditions 
affecting  the  skin  through  the  nervous  system  or  by  means  of  the  blood- 
current.  Cases  of  this  latter  class  are  looked  upon  as  of  toxic  origin. 
The  irritation  of  the  skin  or  the  skin  lesion  is  actually  the  secondary 
manifestation  of  a  disordered  constitutional  state.  Upon  the  non- 
resistant  skin  lesion,  infection  is  implanted  through  exposure  to  the  air 
or  through  scratching,  and  the  result  is  an  eczema  in  which  both  causes 
are  operative.  This  is  the  etiologic  explanation  of  the  majority  of 
the  cases  in  patients  under  two  years  of  age. 

In  view  of  the  foregoing  it  is  plainly  not  possible,  even  were  it  de- 
sirable, to  make  the  attempts  at  differentiation,  such  as  is  found  in  text- 
books dealing  with  dermatology  in  the  adult.  Repeatedly  one  will  find 
a  weeping  or  catarrhal  eczema  in  one  portion  of  an  infant's  body  and 


ECZEMA  585 

on  other  portions  every  variety  of  inflammatory  lesion,  including 
papules,  vesicles,  pustules,  and  fissures.  Moreover,  a  weeping  sur- 
face may  be  replaced  by  perfectly  normal  skin  within  a  day  or  two 
and  then  suddenly  return  within  a  few  hours  under  some  dietetic 
indiscretion. 

Infection  of  the  involved  areas  by  pyogenic  bacteria,  resulting  in 
pustules  and  furuncles,  is  more  common  in  infants  than  in  adults, 
because  of  the  child's  greater  tendency  to  inoculation  through  manipu- 
lation and  scratching,  and  because  of  the  dimished  resistance  offered 
by  a  child  to  pathogenic  organisms. 

Toxic  Origin. — The  cases  of  eczema  that  are  due  to  disordered 
metabolism  or  to  digestive  derangements  are  the  most  frequently  en- 
countered and  by  far  the  most  resistant  to  treatment. 

The  Age. — The  susceptible  age  is  from  one  to  twelve  months.  While 
cases  which  have  developed  during  the  earlier  months  of  life  may  per- 
sist into  the  second  and  third  years,  so  long  a  duration  is  comparatively 
rare,  and  it  is  equally  rare  for  cases  to  develop  after  the  first  year,  the 
latter  fact  implying  that  many  are  cured  spontaneously. 

Physical  Condition. — The  physical  condition  and  vigor  of  the  child 
exert  no  influence  upon  the  development  of  the  disease.  Some  of  my 
healthiest  nursing  babies  who  have  made  most  satisfactory  progress 
and  have  been  well  in  every  other  respect  have  been  sufferers  from 
eczema  until  the  nursing  period  was  over  or  until  nursing  was  discon- 
tinued and  other  food  given.  In  fact,  the  majority  of  my  cases  have 
occurred  in  children  whose  condition  was  otherwise  satisfactory. 
There  have  been  other  patients,  to  be  sure,  who  have  suffered  from 
malnutrition  or  been  difficult  feeding  subjects.  In  some  of  these  ec- 
zema was  possibly  a  factor  in  causing  the  malnutrition,  for  on  account 
of  the  excessive  itching  and  consequent  restlessness  and  sleeplessness, 
strength  had  become  so  markedly  reduced  that  malnutrition  was  just 
as  probably  a  result  as  a  cause  of  the  eczema.  Nevertheless,  a  con- 
sideration of  all  the  cases  encountered  indicates  that  athreptic  and 
poorly  nourished  children  are  surprisingly  free  from  eczema  of  an 
acute  inflammatory  type.  Whatever  process  is  at  fault  is  usually  of 
such  a  nature  as  not  to  interfere  with  nutrition. 

In  a  considerable  proportion  of  the  cases  there  will  be  an  associated 
eczema  of  the  scalp. 

Several  of  my  patients  who  have  been  sufferers  from  eczema  in 
babyhood  have  in  later  life  developed  some  tendency  to  cyclic  illness, 
such  as  recurrent  bronchitis,  recurrent  asthma,  or  recurrent  (cyclic) 
vomiting.  Not  a  few  of  my  eczema  patients  have  been  the  offspring 
of  parents  who  gave  a  history  of  gout. 

Carbon  Incapacity. — While  it  is  not  claimed  that  the  presence  of 
carbohydrate  and  hydrocarbons  in  the  infant's  food  is  the  sole  cause  of 
these  forms  of  toxic  eczema,  my  observation,  covering  many  hundreds 
of  cases,  leads  me  to  believe  that  a  carbohydrate  (sugar)  incapacity 
exists  in  all.  I  look  upon  a  great  majority  of  the  cases  as  exhibiting 
in  capacity  for  fats  (hydrocarbons)  and  certain  carbohydrate  foods, 


586  THE    PRACTICE    OF    PEDIATRICS 

an  intolerance  which  may  be  manifested  by  the  skin  lesions  and  in  no 
other  way. 

The  ingestion  of  fats  and  cane-sugar  is  the  most  prominent  etio- 
logic  factor  in  causing  eczema  in  the  young.  Carbohydrate  in  the 
form  of  baked  flours  appears  to  exert  but  little  influence.  Orange-juice 
and  beef -juice  when  given  in  association  with  a  high  sugar  diet  will  pre- 
cipitate an  attack  in  some  children  or  produce  recurrence  in  a  recovered 
case 

A  possible  reason  for  the  frequency  of  eczema  in  the  young  is  that 
the  young  child  is  unable  to  adjust  himself  to  the  many  varieties  of 
food  and  food  elements  that  are  given  him  whether  natural  or  artificial. 
Not  all  cases  of  eczema  in  infants  admit  of  a  cure  and  yet  I  believe 
that  all  cases  might  be  cured  if  we  dared  draw  our  dietetic  lines  suffi- 
ciently rigid.  This  might  mean  a  clear  skin  but  it  also  might  mean 
faulty  growth  and  malnutrition.  I  have  now  and  then  an  infant 
whom  I  have  entirely  cured  but  do  not  dare  to  keep  him  entirely 
eczema  free  because  of  loss  in  weight.  I  believe  that  proper  growth 
and  right  development  are  more  important  than  personal  appearance. 

Local  Irritation  as  a  Factor. — Traumatic  eczema  may  be  produced 
by  any  form  of  irritation,  such  as  woolen  worn  next  to  the  skin,  counter- 
irritants  applied  for  therapeutic  purposes,  overclothing  in  hot  weather, 
or  scratching  to  relieve  the  itching  caused  by  the  bites  of  insects. 

Symptoms. — The  symptoms  of  eczema  cover  so  wide  a  field  that  a 
description  is  most  difficult.  A  red  inflamed  area  on  the  cheek  and  an 
extensive  acute  general  dermatitis  constitute  the  two  extreme  possi- 
bilities of  the  acute  lesions.  Between  these  extremes  there  is  every 
degree  of  involvement. 

When  an  infection  with  the  staphylococcus  supervenes  we  may  ex- 
pect all  possible  varieties  of  pustules  and  furuncles,  and  the  case  may 
show,  throughout,  the  characteristics  of  chronic  eczema  in  the  adult: 
dry,  scaly,  desquamating  epithelium  on  extensive  reddened  surfaces,  or 
infiltrated  skin  areas  with  diffuse  macules  and  papules  and  abundance 
of  scratch-marks.  The  extensor  surfaces  of  the  arms  and  legs  are  the 
most  frequent  sites  of  election  by  this  form. 

Prognosis. — Eczema  is  one  of  the  diseases  that  require  patient  and 
persistent  treatment  of  the  right  kind.  The  prognosis  is  then  good, 
and  the  results  fairly  prompt.  The  disease  does  not  tend  toward 
recovery,  particularly  during  the  first  year,  although  many  cases 
developing  during  the  first  month  get  well  spontaneously  during  the 
second  year.  In  a  few  subjects  the  tendency  persists  during  the  life- 
time of  the  individual. 

Treatment. — The  management  is  variable,  depending  upon  several 
factors. 

Management  of  the  Breast-fed. — If  the  child  is  a  well-nourished, 
breast-fed  baby  and  presents  the  familiar  picture  of  the  red,  weeping 
cheeks,  with  dry  crustations  extending  to  the  forehead  and  ears, 
seborrhea  of  the  scalp,  and  roughened  skin  over  the  outer  aspect  of  the 
arms,  my  first  step  is  to  look  into  the  life  and  habits  of  both  child  and 


ECZEMA  587 

mother.  The  mother's  life  and  the  nursing  hours  are  to  be  regulated 
along  the  lines  laid  down  under  maternal  nursing  (p.  21).  A  most  im- 
portant requirement  of  these  cases  is  that  the  mother's  bowels  shall  be 
evacuated  at  least  once  daily  and  that  the  same  function  shall  take 
place  in  the  baby.  In  a  case  of  the  character  described  the  child  has 
usually  been  getting  too  much  food,  and  probably  food  high  in  fat. 
The  mother's  milk  should  be  examined  and  the  baby  weighed  before 
and  after  nursings  for  twenty-four  hours  in  order  to  determine  the 
amount  of  milk  taken  at  a  feeding.  As  a  general  observation  it  will 
be  found  that  these  children  do  best  on  four-hour  nursings,  at  6,  10,  2, 
6,  and  10  p.  M.  If  the  mother's  milk  is  found  to  contain  an  excess  of 
fat,  one  ounce  or-  two  of  water  or  barley-water  should  be  given  before 
each  nursing  to  diminish  the  amount  of  fat  ingested. 

For  the  correction  of  constipation  in  the  mother  I  frequently  pre- 
scribe the  following  laxative : 

I^    Ext.  belladonnse .  .  / gr.  iv 

Ext.  nucis  vomicae gr.  viij 

Ext.  cascarse  sagradse 3ij 

M.  Div.  in  capsulas  no.  xxx. 

Sig. — One  at  bedtime. 

By  applying  this  form  of  management  to  the  mother  and  child  I 
have  repeatedly  known  the  eczema  to  subside  very  promptly.  In 
other  cases  I  have  seen  it  improve;  and  in  still  others  persist  without 
the  slightest  benefit. 

The  problem  which  confronts  us  may  be  rendered  difficult  in  differ- 
ent ways.  If  the  child  is  her  first  offspring,  the  mother  feels  keenly  the 
disfiguring  condition  and  demands  a  prompt  cure.  If  this  is  not  forth- 
coming within  a  few  weeks  she  seeks  new  medical  advice.  My  advice 
concerning  the  persistent  breast-fed  cases  is  for  the  mother  to  continue 
to  nurse  the  thriving  child  and  tolerate  the  eczema.  Local  treatment 
should  be  prescribed  to  relieve  as  much  as  possible  the  child's  distress. 
The  mother  may  be  told  that  at  the  time  of  weaning  the  eczema  will 
probably  disappear.  If  weaning  is  insisted  upon,  the  patient  forth- 
with becomes  a  bottle-fed  infant  and  is  treated  accordingly.  The 
eczema  often,  but  not  invariably,  clears  up  promptly  when  nursing  is 
stopped. 

Management  of  the  Bottle-fed. — Every  year  I  see  many  aggravated 
cases  of  eczema  in  bottle-fed  babies  who  have  been  treated  elsewhere, 
often  by  dermatologists,  without  benefit.  Failure  usually  has  been  due 
to  the  fact  that  while  a  great  deal  of  attention  has  been  paid  to  local 
measures,  little  if  any  has  been  directed  to  the  feeding  and  other  details 
of  the  constitutional  care. 

Let  it  be  understood  that  local  applications  in  the  form  of  lotions, 
ointments,  or  powders  have  but  two  uses  in  the  treatment  of  eczema  in 
children.  Their  chief  use  is  that  of  a  sedative.  In  other  instances  a 
stimulant  is  required  and  may  be  supplied  by  local  measures  as  a 
means  of  permanent  cure.  Local  treatment,  however,  is  attended  with 
disappointment.     The  external  condition  may  be  temporarily  relieved 


588  THE    PRACTICE    OF    PEDIATRICS 

in  a  marked  degree,  but  if  the  underlying  systemic  toxic  condition 
exists,  the  disease  returns  with  renewed  vigor. 

In  caring  for  the  bottle-fed  I  find  that  the  most  prompt  results  fol- 
low when  food  low  in  both  fat  and  sugar  is  given.  I  specify  the  use  of 
skimmed  milk  diluted  with  a  cereal  decoction  made  usually  from  bar- 
ley flour  or  Imperial  Granum.  Sugar  is  to  be  avoided.  For  a  child 
under  one  year  of  age,  from  12  to  24  ounces  of  skimmed  milk  are  added 
to  sufficient  cereal  water  to  make  32  ounces.  One  and  one-half  ounces 
of  either  of  the  above  flours  are  required.  The  mother  or  nurse  is  told 
that  the  child  is  not  expected  to  gain  rapidly  on  this  formula. 
Perhaps  no  gain  will  occur  for  a  few  weeks,  but  only  a  very  stubborn 
case  will  fail  to  show  some  response  to  the  change  in  the  diet.  If  con- 
stipation follows  the  change  in  the  food,  magnesia  in  some  form — cal- 
cined, or  milk  of  magnesia — may  be  added  to  the  day's  ration  in  suffi- 
cient amount  to  keep  the  bowels  relaxed  and  the  bicarbonate-of-soda 
is  omitted.  If  the  response  to  treatment  is  not  satisfactory,  or  if  the 
milk  does  not  agree  with  the  patient,  I  employ  an  evaporated  fat-free 
milk  made  for  me  by  Borden  &  Co.,  106  Hudson  St.  Each  ounce  rep- 
resents two  and  two-fifth  ounces  of  skimmed  milk.  In  feeding,  one 
part  of  this  milk  is  added  to  from  three  to  six  parts  of  the  6  per  cent, 
carbohydrate  gruel.  Whether  ordinary  skimmed  milk  or  the  special 
evaporated  milk  is  employed,  this  method  of  feeding  is  continued  only 
until  the  skin  condition  warrants  an  increase,  and  then  the  change  is 
made  to  full  milk  with  the  gruel  diluent.  In  some  instances  sugar  is 
not  used  for  weeks.  In  case  evaporated  milk  has  been  given,  the  change 
to  plain  milk  must  be  made  most  gradually,  one  bottle  of  plain  milk 
replacing  one  of  the  feedings  of  evaporated  milk  every  two  or  three 
days.  In  the  event  of  a  return  of  the  eczema,  it  may  be  necessary  to 
resume  the  former  diet,  consisting  of  the  skimmed  milk  or  evaporated 
milk,  and  perhaps  to  discontinue  full  raw  milk  entirely." 

Illustrative  Case. — One  of  my  patients,  a  baby  otherwise  normal,  had  a  most 
pronounced  general  eczema,  the  entire  skin  surface  being  involved.  For  seven 
months — until  he  was  past  one  year  of  age — I  was  unable  to  give  this  patient 
more  than  1  per  cent,  of  fat.  An  increase  to  1.5  per  cent,  of  fat  would  be  followed 
in  half  an  hour  by  intense  inflammation  and  redness  of  the  skin. 

In  another  case,  almost  as  severe,  which  I  saw  at  the  ninth  month,  I  was  unable 
to  give  plain  milk  in  any  form.  The  condition  was  so  aggravated  that  I  discon- 
tinued entirely  the  fresh  cow's  milk  and  gave  the  child  only  evaporated  milk, 
whereupon  the  skin  cleared  up  promptly  without  any  other  treatment  whatever. 
After  about  six  weeks  a  further  trial  of  full  milk  in  small  quantities  was  at  once 
followed  by  a  prompt  return  of  the  eczema.  At  different  intervals  the  plain  milk 
was  given  for  one  or  two  feedings  daily,  but  this  we  were  always  obliged  to  dis- 
continue, because  of  the  signs  of  the  old  trouble  which  immediately  reappeared 
after  two  or  three  of  such  feedings. 

In  treating  these  obstinate  cases,  as  the  urine  is  usually  very  acid 
and  a  deposit  of  urates  will  be  found  on  the  napkin,  I  invariably  give 
bicarbonate  of  soda,  one  grain  to  one  ounce  of  food,  or  ten  grains  of 
citrate  of  potash  five  or  six  times  daily.  I  look  upon  citrate  of  potash 
in  fairly  large  doses,  five  to  ten  grains  every  two  hours,  as  a  valuable 
aid  during  the  acute  stage  of  eczema.  It  may  be  discontinued  after 
the  erythema  and  weeping  has  subsided. 


ECZEMA  589 

If  a  high  fat  feeding  has  been  practised,  cure  may  at  times  be 
effected  simply  by  the  use  of  full  cow's  milk,  with  the  gruel  diluent. 

The  successful  management  of  eczema  (non-traumatic)  depends 
upon  our  ability  to  discover  the  disturbing  food  factors,  to  eliminate 
them  if  we  dare,  or  if  possible  immunize  the  patient  to  such  food  or 
foods. 

Local  Treatment. — In  view  of  what  has  been  said,  little  is  to  be  ex- 
pected from  local  measures.  As  a  rule,  too  strong  lotions  and  oint- 
ments are  employed  and  help  to  keep  up  the  irritation,  producing  harm 
rather  than  benefit.  Vasehn  is  often  used  as  a  base,  and  this  in  itself 
is  irritating  to  many  skins.  In  facial  eczema  of  an  active  type  in  young 
infants,  however,  the  parts  should  be  protected  from  scratching  and 
pillow-rubbing.  This  is  best  accomphshed  by  the  use  of  a  mask  (p. 
591)  under  which  are  placed  strips  of  old  linen  on  which  the  following 
paste  ointment  is  applied: 

I^     Pulv.  zinci  oxid, 

Pulv.  amyli aa  Sjj 

Ungt.  aq.  rosse.. q.  s.  ad  §ij 

This  ointment  should  be  freshly  applied  three  times  daily.  The  child's 
skin  is  not  to  be  bathed  with  water,  but  cleansed  with  sterilized  sweet 
oil.  When  the  weeping  has  subsided,  some  preparation  of  tar  may  be 
employed.  An  ointment  composed  of  unguentum  picis,  U.  S.  P.,  1  part, 
with  unguentum  aquae  rosse,  from  4  to  6  parts  (the  strength  used  de- 
pending upon  the  irritability  of  the  skin),  may  be  applied  with  much 
benefit  morning  and  evening.  The  ointment  should  be  thickly  spread 
over  old  linen  and  held  firmly,  yet  without  great  pressure,  over  the 
parts.  If  the  existing  irritation  is  at  all  increased,  the  amount  of  tar 
used  must  be  diminished.  If  the  itching  is  not  considerably  relieved 
by  the  application,  5  grains  of  menthol  or  5  grains  of  salicylic  acid  may 
be  added  to  each  ounce  of  the  ointment.  For  the  weeping  or  intensely 
inflamed  surface,  Euresol  (Merck)  has  been  used  by  me  with  a  great 
deal  of  benefit.  In  this  stage  it  is  best  used  in  a  solution  of  1  to  3  per 
cent.  The  solution  is  to  be  applied  very  gently  and  allowed  to  dry. 
It  may  be  applied  at  intervals  of  three  to  four  hours.  When  the  weep- 
ing ceases  and  the  skin  becomes  dry  and  desquamating,  an  ointment 
of  Euresol  1  per  cent,  to  2  per  cent,  in  unguentum  aqua  rosse,  applied 
three  times  daily  often  supplies  very  substantial  relief. 

Bathing. — All  infants  and  young  children  suffering  from  generalized 
eczema  should  not  be  bathed.  Water  is  a  decided  irritant  to  the  skin. 
For  cleansing  purposes  during  the  acute  stage  sterilized  olive  oil  or 
liquid  albolene  may  be  used.  When  the  skin  permits  of  bathing,  the 
patient  should  have  the  advantage  of  the  soda  or  bran  bath  (p.  780). 
Unnecessary  friction  is  to  be  avoided  at  all  times. 

Clothing. — It  is  my  custom  to  have  the  clothing  which  comes  in 
contact  with  the  skin  fined  with  thin  linen.  Wool  worn  next  to  the  skin 
will  frequently  retard  recovery. 

Traumatic  Eczema. — The  successful  management  of  eczema  due  to 
external  caUSes  consists  in  the  removal  of  the  source  of  the  irritation. 


590  THE    PRACTICE    OF    PEDIATRICS 

In  some  cases  lining  the  underclothing  with  old  linen  or  the  use  of  linen 
mesh  underwear  will  solve  the  entire  problem.  Local  treatment,  when 
necessary,  is  afforded  by  the  soothing  and  stimulant  applications  pre- 
viously described. 

ECZEMA  INTERTRIGO  OR  ERYTHEMA  INTERTRIGO 

This  form  of  eczema  is  an  affection  resulting  from  persistent  ir- 
ritation due  to  moisture  or  friction.  The  primary  condition  of  macera- 
tion soon  develops  into  a  chronic  eczema.  This  occurs  with  greatest 
frequency  in  fat  children,  but  may  develop  in  any  child  through  neglects 
In  fact,  intertrigo  is  often  a  mark  of  ignorance  and  neglect. 

Location. — The  parts  most  affected  are  the  lower  abdomen,  the 
inner  aspects  of  the  thighs,  and  the  buttocks.  In  neglected  cases  I 
have  repeatedly  seen  the  process  cover  the  entire  skin  surface  from  the 
umbilicus  to  the  lower  third  of  the  thigh.  Other  parts  usually  found 
affected  are  the  skin  folds  of  the  neck,  the  groin,  and  axillae  and  the 
flexor  surfaces  at  the  elbow-joint  where  contiguous  portions  of  skin  are 
subjected  to  chafing. 

Neglected,  athreptic,  and  poorly  nourished  babies  afford  many  of 
these  cases.  Among  out-patients,  I  have  seen  infants  who  presented  a 
series  of  linear  ulcers  in  the  groin,  productive  of  entire  destruction  of 
the  skin.  In  a  few  such  instances  resulting  infection  of  the  glands  in 
the  groin  has  produced  an  inguinal  adenitis. 

Prognosis. — All  cases  recover  promptly  if  proper  care  is  exercised 
in  carrying  out  the  suggestions  offered. 

Treatment. — The  management  consists  in  separating  the  opposed 
diseased  surfaces  by  pledgets  of  cotton,  gauze,  or  old  linen,  freely 
dusted  with  equal  parts  of  starch  and  oxid  of  zinc.  As  soon  as  the 
material  becomes  moist  a  fresh  dressing  should  be  substituted. 

When  there  is  much  associated  involvement  of  the  skin  over  the 
genitals,  lower  abdomen,  thighs,  and  buttocks,  care  must  be  exercised 
that  the  parts  be  kept  free  from  decomposing  urine. 

Except  in  cases  of  the  seborrheic  type  (p.  595)  the  management 
consists  in  neutralizing  the  urine  by  the  use  of  bicarbonate  of  soda, 
three  grains  three  times  daily,  and  in  protecting  the  skin  surface  from 
irritating  discharges  by  attention  to  the  napkin.  Dusting-powders  are 
of  very  little  use. 

A  most  satisfactory  procedure  which  I  have  followed  with  success 
for  years,  even  in  the  most  unpromising  cases,  is  as  follows :  The  mother 
or  nurse  is  instructed  to  keep  close  watch  of  the  napkin  and  change  it  as 
soon  as  it  is  soiled.  She  is  further  instructed  to  prepare  pieces  of  gauze 
or  old  linen  of  such  shape  and  size  as  to  cover  the  denuded  surfaces. 
On  these  slips  of  linen  she  is  directed  to  spread  a  thick  layer  of  zinc  oint- 
ment (U.  S.  P.)  to  which  10  per  cent,  white  wax  has  been  added.  This 
dressing  is  kept  applied  to  the  parts  and  is  to  be  changed  several  times 
daily.  If  the  ointment  is  simply  spread  over  the  skin,  it  will  soon  be 
absorbed  by  the  napkin  and  be  of  no  service. 

Over  the  dressing  the  napkin  is  placed.     The  irritating  urine  is- 


ECZEMA   IN    OLDER    CHILDREN 


591 


thus  prevented  by  the  ointment  dressings  from  coming  in  contact  with 
the  skin.  An  additional  quantity  of  absorbent  cotton  placed  next  to 
the  genitals  serves  to  absorb  the  urine  as  it  is  passed  and  thus  prevents 
its  general  distribution  over  the  parts.  When  the  case  is  well  advanced 
toward  recovery,  the  maintenance  of  scrupulous  cleanliness  and  the 
application  of  a  dusting-powder  composed  of  equal  parts  of  powdered 
starch  and  oxid  of  zinc  will  be  sufficient. 

The  Mask. — The  itching  produced  by  facial  eczema  is  often  most 
intense.  In  order  to  effect  a  cure,  scratching  and  rubbing  the  parts 
must  be  prevented.  The  Herty 
mask  (Fig.  77)  fulfils  this  pur- 
pose admirably.  The  ointment 
or  lotion  is  placed  on  clean 
linen,  which  rests  on  the  in- 
volved parts,  and  over  this  is 
placed  the  mask,  a  pattern  of 
which  is  shown  in  Fig.  78. 
Opening  A  is  sufficiently  large  to 
furnish  space  for  the  eyes,  nose, 
and  mouth.  An  elastic  band, 
passing  over  the  upper  lip,  draws 
the  sides  of  the  opening  together, 
insuring  protection  to  the  cheeks, 
which  are  usually  most  severely 
affected.  B  and  C  pass  over  the 
ears  to  the  back  of  the  head, 
where  they  are  united.  The 
mask,  which  should  be  made  of 
muslin  or  thin  old  Knen,  is  to  be 
renewed  daily. 

The  Strait-jacket. — The  tendency  for  the  patient  to  scratch  the 
involved  parts  not  only  keeps  up  the  trouble  indefinitely,  but  opens  a 
way  for  the  development  of  severe  dermatitis,  furunculosis,  and  cellu- 
litis as  a  result  of  infection  from  the  finger-nails.  One  of  the  best  agents 
for  preventing  scratching  during  the  sleeping  hours  is  the  Thomas 
modified  strait-jacket  (Fig.  79).  This  is  made  of  muslin  and  must  be 
fitted  to  the  patient.  The  child  is  slipped  into  the  jacket  feet  first. 
The  opening  A  incircles  the  thorax  directly  under  the  arms.  The 
opening  B  is  closed  about  the  neck  with  the  attached  tapes.  The  cord 
which  is  used  to  close  the  end  of  the  sleeves  may  be  tied  to  the  side  of 
the  crib  or  pinned  to  the  bedding.  Children  readily  accustom  them- 
selves to  lying  on  the  back,  a  posture  which  the  use  of  the  jacket 
necessitates. 

It  is  no  kindness  to  allow  a  child  to  continue  the  irritation  of  sur- 
faces already  badly  involved. 

ECZEMA  IN  OLDER  CHILDREN 

We  have  been  considering  eczema  in  children  under  two  years  of 
age.     From  the  eighteenth  month  to  the  second  year  certain  develop- 


Fig.  77. — The  Herty  mask  in  position. 


592 


THE    PRACTICE    OF    PEDIATRICS 


mental  changes  take  place  in  the  child  which  render  him  much  less 
susceptible  to  the  toxic  agents  capable  of  producing  the  eczema. 
The  ratio  of  cases  seen  after  the  second  year  to  those  under  one  year 
of  age  is  about  one  to  ten. 


Fig.  78. — Pattern  for  the   Herty  mask. 

Etiology. — Gouty  antecedents  have  been  the  rule  in  my  cases. 
In  older  children  as  well  as  in  the  young,  eczema  is  of  metabolic  and 
gastro-intestinal  origin.     We  find  that  in  the  causation  certain  sub- 


Fig.  79. — Thomas'  modified  strait-jacket. 


stances  play  an  important  part,  particularly  milk-fats  and  sugars. 
Certain  fruit  acids  and  meat  extractives  have  also  proved  operative 
in  an  etiologic  way.  Thus  grape-fruit,  orange-juice,  strawberries, 
tomatoes  and  beef-juice  have  all  been  proved  the  immediate  cause  in 
a  sufficient  number  of  cases  to  establish  the  mode  of  origin  beyond  the 
slightest  doubt. 


ECZEMA   IN    OLDER   CHILDREN 


593 


Some  of  the  cases  of  eczema  in  children  are  unquestionably  of 
intestinal  origin  owing  to  the  absorption  of  toxic  substances  from  the 
intestinal  canal.  Such  origin  of  the  disease  may  be  suggested  by  habit- 
ual constipation,  hght  colored  and  foul  stools,  and  distended  abdomen. 
This  mode  of  etiology  has  further  been  proved  by  the  recovery  and 
continued  well-being  of  the  patient  when  the  constipation  is  reheved 
and  a  rational,  simple  diet  free  from  milk-fat  and  excessive  sugar  has 
been  instituted.  Finally,  it  is  to  be  remembered  that  in  older  children 
anemia  and  malnutrition  may  play  an  important  part  in  causing 
eczema. 

Symptoms. — The  cases  of  acute  facial  eczema  are  comparatively 
rare  except  in  younger  children,  but  are  occasionally  encountered. 


Fig.  80. — Thomas'  modified  strait-jacket  in  position. 


The  tendency  to  development  of  pustules  and  furnucles  is  also  much 
less  in  children  over  two  years  of  age.  Weeping  and  desquamating 
surfaces,  however,  are  common,  and  squamous  patches  and  fairly 
extensive  mfiltrated  areas  are  frequently  found  in  different  portions  of 
the  body.  Perhaps  the  most  frequent  manifestation  at  this  age  is 
what  is  referred  to  by  various  writers  as  ''neurotic"  or  "reflex" 
eczema.  The  predominating  lesions  in  this  form  are  papules  which 
may  exist  in  great  number,  especially  over  the  extensor  surfaces  of 
the  arms  and  legs.  Often  the  individual  papule  is  tipped  by  a  black 
speck  which  represents  dried  blood  and  dirt  resulting  from  scratching. 
In  cases  that  have  existed  for  some  months  there  is  a  general  thickening 
and  hardening  (infiltration)  of  the  affected  skin,  with  surrounding  spots 
of  inflammation,  which  is  more  the  result  of  trauma  from  treatment 
than  due  to  the  disease  itself. 
38 


594  THE    PRACTICE    OF    PEDIATRICS 

Eczema,  by  reason  of  the  wide  variety  of  its  forms,  may  involve 
any  portion  of  the  skin.  The  skin  about  the  umbiHcus  is  one  of  the 
sites  occasionally  selected  by  the  disease  in  older  children. 

Ilhistrative  Cases. — One  of  my  most  troublesome  cases,  which  had  been  treated 
by  various  physicians  for  two  years,  was  that  of  a  girl  four  years  of  age  who  pre- 
sented a  round,  red,  desquamating  area  on  the  right  cheek,  %  inch  in  diameter. 

In  the  case  of  a  boy  four  years  old  an  acute  weeping  eczema  had  covered  both 
buttocks. 

A  girl  of  five  had  suffered  at  intervals  for  eighteen  months  with  an  eczema 
between  the  fingers' of  the  right  hand. 

I  have  a  most  interesting  girl  patient  of  eight  years,  who,  after  partaking  of 
sugar  in  any  form  and  in  the  smallest  amount,  beef-juice,  or  any  acid  fruit-juice, 
will  develop  an  acute  eczema  of  the  face,  requiring  two  weeks  for  recovery.  The 
mother,  who  is  very  intelligent,  had  discontinued  milk  before  the  case  came 
under  my  observation  because  of  attacks  of  cyclic  vpmiting  from  which  the  child 
suffered,  and  which  the  mother  stated  were  worse  when  milk  was  taken.  Milk 
also  produced  hives  and  "poisoned"  the  child,  so  that  the  mother  begged  me 
not  to  ask  her  to  give  the  patient  milk.  We  found  that  the  child  could  take  fat- 
free  milk.  In  this  case  there  was  a  marked  history  of  gout  on  both  sides  of  the 
family.  The  maternal  grandmother  required  crutches,  the  mother  had  cyclic 
vomiting  as  a  child  and  sick  headaches  as  an  adult,  and  "had  been  treated  for 
uric  acid  all  her  life,"  and  the  father  stated  that  he  was  scarcely  ever  free  from  pain 
in  his  joints  or  muscles. 

Another  girl  four  years  old,  of  decidedly  gouty  ancestry,  suffered  intensely 
during  infancy  from  eczema,  which  was  with  difficulty  kept  under  control.  When 
two  years  old  she  developed  recurrent  bronchitis  with  asthma  of  a  most  severe  type, 
and  she  has  had  several  attacks  of  spasmodic  croup.  Milk-fat,  sugar,  fruit-juice, 
or  beef-juice  in  the  case  of  this  child  produces  an  intense  eczema. 

These  cases  all  recovered  under  dietetic  measures  alone. 

Prognosis. — The  prognosis  is  good,  and  the  results  are  usually 
quite  prompt  following  the  right  line  of  management.  Relapses  are 
not  uncommon,  however,  because  the  treatment  is  so  largely  dietetic, 
and  the  best  of  people,  when  well,  forget  dietetic  regulations  more 
readily  than  anything  else. 

Treatment. — Our  first  step  in  the  management  of  eczema  in  a  child 
is  to  learn  all  there  is  to  know  about  the  case.  A  full  physical  examina- 
tion is,  therefore,  made  and  the  condition  of  the  blood  and  urine  is  ascer- 
tained. The  child  is  then  given  a  regime  of  living  suited  to  his  con- 
dition. A  diet  schedule  is  furnished,  the  hours  for  rest  and  sleep  and 
play  are  indicated,  and  if  there  is  defective  appetite  or  anemia,  suitable 
added  treatment  is  prescribed.  One  full  bowel  movement  a  day  is 
required.  It  has  been  a  matter  of  no  little  surprise  to  me  to  find  the 
eczema  gradually  disappearing  as  a  result  of  improvement  in  the  child's 
general  condition.  Through  the  correction  of  digestive  disorders  and 
the  establishment  of  right  living,  I  have  repeatedly  seen  cases  of 
persistent  eczema  clear  up  entirely  without  other  treatment. 

In  a  general  way  the  suggestions  laid  down  for  the  management  of 
deUcate  children  (p.  122)  may  apply.  In  the  diet  I  allow  little  or  no 
sugar.  Milk,  if  used,  is  always  skimmed.  Butter,  strawberries, 
tomatoes,  and  acid  fruits  are  not  allowed.  The  use  of  green  vegetables 
is  to  be  encouraged  for  the  reason  that  they  possess  distinct  thera- 
peutic value.  An  absolute  salt-free  diet  is  not  insisted  upon,  but  only 
sufficient  salt  is  used  to  make  the  food  barely  palatable.  Citrate  of 
potash,  referred  to  on  p.  588,  is  equally  useful  in  those  cases. 


SEBORRHEA  595 

Contrary  to  the  established  belief  I  find  arsenic  of  very  little  direct 
value,  although  in  improving  the  general  physical  state  of  the  patient 
it  may  be  of  service.  I  believe  rhubarb  and  soda  and  cascara  to  be  of 
much  greater  value. 

Local  Treatment. — ^Local  treatment  may  be  of  advantage  in  relieving 
the  itching.  In  using  skin  applications  for  eczema  in  children  it  is 
necessary  to  exercise  considerable  care  in  not  having  the  lotions  or 
ointments  too  strong,  in  which  event  they  will  act  as  irritants  and  do 
harm.  For  the  acute  cases,  in  which  there  are  much  inflammation  and 
itching,  I  frequently  use  a  combination  of  zinc  oxid  ointment,  U.  S.  P., 
and  menthol,  as  follows: 

I^     Mentholis gr.  x 

Ungt.  zinci  oxidi § j 

After  the  acute  dermatitis  has  somewhat  subsided,  the  following  oint- 
ment may  be  used  with  advantage : 

I^     Acidi  salicylici gr.  x 

Ungt.  picis,  U.  S.  P gss 

Ungt.  aquae  rosae q.  s.  ad  5  ij 

This  ointment  should  be  used  twice  daily,  the  strength  of  the  tar 
and  the  salicylic  acid  being  increased  if  necessary  as  the  case  progresses. 
It  is  always  well  to  begin  with  an  application  of  a  reduced  strength  and 
to  increase  the  strength  later  as  the  case  may  require. 

The  ointment  should  be  bound  to  the  parts  so  as  to  completely 
cover  the  surfaces,  thereby  insuring  the  full  benefit  of  the  treatment 
and  at  the  same  time  protecting  the  skin  from  further  irritation  by 
scratching.  The  case  may  respond  very  promptly,  or  it  may  be  most 
obstinate  and  require  several  weeks  of  both  dietetic  and  local  treatment. 

Bathing. — When  the  skin  is  acutely  involved,  water  should  not  be 
allowed  to  come  in  contact  with  it.  Sterilized  olive  oil  should  be  used 
for  cleansing  purposes.  On  uninvolved  portions  of  the  body,  and  in 
chronic,  inactive  cases,  the  soda  or  bran  bath  (p.  780)  may  be  used. 

SEBORRHEA 

Seborrhea  is  usually  classified  as  an  eczema.  It  is  due  to  excessive 
secretion  and  activity  of  the  sebaceous  glands,  and  is  regarded  by  some 
observers  simply  as  a  derangement  of  function.  By  others  it  is  believed 
to  be  due  to  a  specific  infection. 

Seborrhea  Capitis  (Milk  Crust). — The  form  in  which  the  condition 
is  most  frequently  seen  in  children  develops  on  the  head,  producing 
thick,  dirty,  yellow  crusts,  commonly  known  as  "milk  crust."  The 
exudation  consists  of  sebum,  dirt,  and  desquamated  epithelium.  In 
mild  cases  the  crusts  may  be  isolated  or  combined  in  one  large  patch 
with  several  surrounding  smaller  areas.  In  other  cases  the  exudation 
is  thick  and  uniform,  and  covers  the  vertex  of  the  head  like  a  mask. 

Treatment. — The  first  step  in  the  treatment  is  to  remove  the  crusts. 


596  THE    PRACTICE    OF    PEDIATRICS 

The  hair  should  be  cut  very  short.  If  only  a  few  areas  are  involved, 
anointing  the  parts  with  vaselin  several  times  daily  will  soften  the 
exudate,  so  that  it  may  be  removed.  If  the  crust  is  thick  and  extensive, 
it  should  be  softened  with  sterilized  olive  oil,  applied  on  gauze  or  old 
hnen  which  is  well  saturated  with  the  oil,  and  held  in  place  by  a  cap  of 
cheese-cloth.  If  the  dressing  is  applied  at  bedtime  the  crusts  may 
often  be  removed  the  following  morning.  In  cases  in  which  the  exuda- 
tion has  existed  for  a  long  time  and  is  very  hard,  frequent  fresh  applica- 
tions of  the  oil  for  two  or  three  days  may  be  required  to  soften  the  crusts 
sufficiently  for  their  removal  without  injury  to  the  skin.  When  thor- 
oughly softened,  they  should  be  washed  off  with  Castile  soap  and  warm 
water.  The  underlying  skin  will  then  usually  be  found  to  be  reddish 
and  slightly  inflamed.  To  this  should  be  applied  an  ointment  of 
resorcin  and  vaselin,  15  grains  to  the  ounce.  The  ointment  should  be 
spread  on  linen  or  lint  and  applied  to  the  parts  with  the  aid  of  the  gauze 
cap.  In  all  except  the  most  aggravated  cases  this  treatment,  used  only 
at  night  will  be  sufficient.  In  the  severe  cases  a  few  additional  ap- 
pUcations  of  the  ointment  during  the  day  will  usually  be  effective. 
A  few  days'  treatment  will  often  relieve  the  worst  cases  of  seborrhcea 
capitis  after  the  scalp  has  been  freed  from  crusts.  I  have  yet  to  see 
a  case  which  will  not  respond  when  this  treatment  is  properly  carried 
out.  It  is  to  be  remembered,  however,  that  there  is  a  tendency  for 
the  exudation  to  return.  Mothers  and  nurses  should  be  instructed  to 
keep  the  ointment  in  the  nursery  for  use  upon  the  first  appearance  of 
the  exudation.  In  children  seborrheic  eczema,  according  to  my  ob- 
servation, is  comparatively  unusual  in  other  portions  of  the  body, 
although  by  extension  of  the  seborrhea  of  the  scalp,  the  forehead  and 
face  may  be  involved.  In  these  situations,  also,  resorcin  is  useful,  but 
must  be  used  in  much  weaker  strength,  ranging  from  0.5  to  1  per  cent. 

Seborrhea  Intertrigo. — At  rare  intervals  cases  of  intertrigo  are 
encountered  upon  which  no  impression  whatever  is  made  by  the 
methods  of  treatment  suggested  on  p.  590.  Several  years  ago  Dr. 
George  T.  Elliott,  of  New  York,  called  my  attention  to  the  fact  that 
these  cases  were  of  seborrheic  origin,  and  that  a  change  from  the 
ordinary  treatment  to  that  ordinarily  used  for  seborrheic  eczema  would 
prove  his  contention.  In  the  cases  in  question,  and  in  those  that  I  have 
since  seen,  the  point  made  by  him  has  been  confirmed  by  the  treatment. 
Cases  of  seborrhcea  intertrigo  are  generally  associated  with  seborrhea 
elsewhere,  usually  upon  the  head,  and  show  erythema,  a  tendency 
to  dryness  of  the  skin,  and  desquamation. 

The  treatment  in  this  form  of  intertrigo  consists  in  enforcing  cleanli- 
ness and  a  proper  diet,  as  mentioned  under  Intertrigo,  p.  590.  In 
addition  to  the  usual  means,  from  0.5  to  1  per  cent,  of  resorcin  should  be 
added  to  the  zinc-oxid  ointment  which  is  used  as  a  dressing.  Euresol 
is  here  used  with  benefit  in  strength  of  1  to  2  per  cent,  in  unguentum 
aqua  rosse.  Seborrheic  eczema,  although  not  as  difficult  of  manage- 
ment as  the  other  forms  of  ezcema  in  children,  nevertheless  shows  a 
great  tendency  to  return,  particularly  in  cases  of  low  vitality. 


BED-SORES    (dECUBITIS)  597 

PSORIASIS 

Psoriasis  is  an  unusual  disease  in  children,  that  is,  unusual  to 
pediatrists  and  practitioners.  Bulkley  has  seen  the  disease  in  a 
baby  four  months  old.  Dermatologists  are  agreed  that  from  10  to 
15  per  cent,  of  the  cases  that  come  under  observation  are  under  10 
years  of  age.  The  disease  is  essentially  chronic,  occurring  every 
winter  and  often  disappearing  with  the  advent  of  warm  weather. 

The  Lesions. — The  lesions  of  psoriasis  possess  similar  features  which 
renders  the  diagnosis  of  little  difficulty.  The  eruption  first  appears  as 
brown  flat  papules  with  a  tendency  to  desquamation.  When  the  dis- 
ease comes  under  observation  there  is  usually  a  series  of  areas  of  the 
papules  which  have  coalesced  and  formed  plaques  which  are  covered 
with  white  or  grayish  scales.  When  the  scales  are  forcibly  removed 
small  bleeding  points  may  be  seen.  The  lesions  are  very  variable  in 
number,  size  and  location.  In  several  of  my  patients  they  were  situ- 
ated on  the  forehead  at  the  margin  of  the  hair.  Here,  thick  infiltrated, 
desquamating  crusts  may  form. 

The  site  of  the  eruption  is  usually  on  the  extensor  surfaces,  often 
about  the  knees  and  elbows.  There  may  be  but  two  or  three  small 
areas  or  large  portions  of  the  skin  surface  may  be  involved.  The  nails 
and  hands  and  palmar  aspect  of  the  soles  of  the  feet  are  rarely 
affected.  Staining  of  the  skin  at  the  site  of  the  eruption,  more  or  less 
persistent,  remains.  Symptoms  other  than  the  lesion  are  of  little 
moment.     There  is  usually  some  itching  but  usually  not  severe. 

Etiology, — The  cause  of  psoriasis  is  not  known.  Bulkley  claims 
it  to  be   due  to  "some  constitutional  error" — a  break  in  metabohsm. 

Treatment. — Treatment  in  my  hands  has  been  very  unsatisfactory. 
The  case  may  be  relieved  by  an  exclusive  vegetable  diet,  which  means 
an  absence  of  meat,  fish,  poultry  and  eggs.  Bulkley  claims  that  cases 
may  be  cured  and  remain  well  when  managed  in  this  way. 


BED-SORES  (DECUBITIS) 

During  any  illness  productive  of  greatly  disturbed  nutrition  or 
emaciation,  such  as  cerebrospinal  meningitis,  typhoid  fever,  and  em- 
pyema, constant  pressure  on  the  prominent  bony  parts  interferes  suf- 
ficiently with  the  circulation  to  cause  destruction  of  the  integument. 
The  most  frequent  sites  for  decubitus  in  children  are  the  sacrum,  the 
heels,  and  the  back  of  the  head. 

The  condition  is  best  prevented  by  special  care  in  maintaining 
cleanliness,  by  keeping  the  bed-linen  smooth,  and  frequently  changing 
the  position  of  the  patient,  and  by  the  free  application  of  any  simple 
powder,  such  as  equal  parts  of  powdered  zinc  oxid  and  starch. 

Treatment. — The  parts  as  they  become  sensitive  and  show  redness 
should  be  bathed  several  times  a  day  with  alcohol.  If  this  does  not 
relieve  the  condition,   the  areas  should  be  covered  with  diachylon 


598 


THE    PRACTICE    OF    PEDIATRICS 


plaster  so  as  to  insure  complete  protection.     The  air-cushion  or  the 
water-bed  may  be  necessary  in  any  prolonged  illness. 

When  the  back  of  the  head  is  involved,  the  scalp  should  be  shaved 
and  the  head  allowed  to  lie  in  a  home-made  head-rest  which  is  con- 
structed as  follows  (Fig.  81):  A  piece  of  fairly  stiff  wrapping  paper, 
four  inches  wide,  is  twisted  into  a  rope,  of  which  a  circle  four  to  five 

inches  in  diameter  is  made 
by  bringing  the  ends  to- 
gether. The  paper  is  then 
wrapped  thickly  with  ab- 
sorbent cotton,  which  is  in 
turn  wrapped  with  a  two- 
inch  roller  bandage. 

NEVUS  (BIRTH-MARK) 

A  nevus  is  a  congenital 
new-formation  in  the  skin. 
The  growth  may  be  pig- 
mentary or  vascular. 

Etiology. — None  of  the 
various  theories  which  have 
been  advanced  to  account 
for  the  existence  of  nevi  is 
well  established.  The  fre- 
quent occurrence  of  vascular 
nevi  in  such  regions  as  the 
back  of  the  head  and  nape  of  the  neck  has  given  rise  to  the  belief 
that  these  marks  may  be  produced  by  intra-uterine  pressure. 
Virchow,  however,  emphasized  the  predilection  of  the  growths  for 
the  embryonic  fissures  of  the  skin,  where  slight  irritation  would  be 
capable  of  exciting  anomalous  vascular  development.  Females  are 
more  frequently  affected  than  males. 

Symptomatology. — The  pigmentary  moles  comprise  noevus  pilus,  a 
smooth,  pigmented  spot;  ncevus  pilosus,  the  hairy  mole;  ncevus  verru- 
cosus, a  raised  warty  growth;  ncevus  lipomatodes,  which  contains  hy- 
pertrophied  fat  tissue;  and  ncevus  linearis,  which  is  usually  unilateral, 
and  frequently  follows  the  distribution  of  cutaneous  nerves.  The 
moles  may  be  brown  or  black,  single  or  multiple,  and  are  most  common 
on  the  face,  neck,  and  back. 

Vascular  nevi  range  in  character  from  small  capillary  angiomata  to 
large,  raised,  pulsating  tumors.  One  of  the  most  disfiguring  marks  is 
the  ncevus  flammeus,  or  "port- wine  stain."  This  is  a  bright  red  or 
purple  spot,  of  irregular  outline  and  more  or  less  uneven  surface,  com- 
monly found  on  the  face,  and  covering  an  area  which  may  be  as  large 
as  the  palm.  The  true  vascular  nevi  all  become  pale  under  pressure, 
and,  conversely,  show  the  deepest  color  when  the  local  blood-pressure  is 
increased  by  such  acts  as  crying  or  coughing. 

Prognosis. — Pigmentary   moles   rarely   disappear   spontaneously. 


Fig.  81. — Head-rest  to  prevent  bed-sores. 


NEVUS  (birth-mark)  599 

The  simpler  forms  of  angioma  may,  however,  occasionally  undergo 
atrophy,  or,  on  the  contrary,  increase  in  size  over  a  Hmited  period. 

Treatment. — Satisfactory  results  in  treatment  caU  for  the  exercise 
of  considerable  patience  and' skill.  Many  of  the  smaller  capillary  nevi 
may  be  made  to  disappear  under  the  pressure  produced  by  repeated 
applications  of  collodion.  In  more  pronounced  cases  "stippling"  with 
nitric  acid,  electrolysis  by  multiple  punctures,  and  exposure  to  the  x- 
ray  are  methods  of  value.  Jackson  has  emphasized  particularly  the 
value  of  freezing  by  liquid  air  or  carbon  dioxide  snow.  In  suitable 
cases  excision  may  be  performed.  Mention,  however,  should  be  made 
of  the  tragic  results  which  have  occasionally  followed  mechanical  inter- 
ference with  certain  forms  of  mole.  Although  it  is  possible  that 
metastasis  with  general  sarcomatosis  is  a  phenomenon  confined  to 
adults,  no  one  who  has  witnessed  such  an  occurrence  will  advocate 
conservative  surgery  in  the  removal  of  pigmental  growths.  Unless 
excision  can  be  thorough  and  complete,  it  should  not  be  attempted. 


XV.  DISEASES  OF  THE  EAR 

EARACHE 

In  every  case  of  earache  in  an  infant  or  young  child  the  ear-drum 
should  be  examined.  It  may  show  intense  congestion  and  bulging, 
requiring  immediate  incision,  or  only  slight  congestion  about  the  pe- 
riphery of  the  drum  and  at  the  tip  of  the  malleus.  When  the  latter  con- 
dition exists  there  are  various  means  of  relieving  the  pain,  the  most 
effectual  probably  being  instillation  into  the  ear  of  equal  parts  of  a 
warm  4  per  cent,  solution  of  cocain  and  camphor-water,  five  drops  of 
which  are  dropped  into  the  ear,  and  repeated  every  half-hour  if  neces- 
sary, after  which  dry  heat  may  be  applied  by  the  use  of  a  hot-water 
bottle  or  a  salt  bag.  I  have  frequently  relieved  severe  attacks  of  ear- 
ache by  means  of  a  hot-water  douche  with  one  pint  of  water  at  110°F., 
using  a  douche-bag  or  a  fountain  syringe.  '  When  the  pain  is  not 
promptly  relieved,  the  ear  should  be  carefully  watched,  particularly 
if  there  is  recurrent  shooting  pain,  a  throbbing  sensation,  or  a  feeling 
of  fullness  in  the  ear.  In  young  children  a  rise  in  temperature  associ- 
ated with  earache  is  often  indicative  of  an  acute  infectious  process  in 
the  middle  ear,  and,  in  addition  to  the  treatment  suggested,  the  ear 
should  frequently  be  examined,  in  order,  if  necessary,  to  insure  early 
incision  of  the  drum  membrane. 

DEAFNESS 

Hearing  is  probably  established  in  the  newly  born  during  the  first 
two  or  three  days  of  life.  During  the  early  months  of  life  the  hearing 
is  very  acute.  Acquired  deafness  is  not  at  all  unusual,  however,  even 
in  comparatively  young  children.  Among  its  most  frequent  causes  is 
an  extension  of  an  inflammation  from  the  throat  to  the  tubal  mucous 
membrane.  In  diphtheria,  in  the  exanthemata,  in  grip,  in  tonsillitis, 
and  in  many  other  ailments  of  early  life  there  is  an  associated  inflam- 
mation of  the  nasopharyngeal  structures.  Unless  infection  of  the 
middle  ear  occurs,  deafness  is  usually  of  a  very  temporary  nature. 
Persistent  deafness  may  be  the  result  of  enlarged  tonsils,  adenoids,  or 
organized  changes  in  the  canal  or  in  the  middle  ear.  Among  the  most 
frequent  causes  of  persistent  deafness  in  children  are  adenoids,  scarlet 
fever,  and  cerebrospinal  meningitis.  Congenital  syphilis  is  an  infre- 
quent cause  of  deafness.  Response  to  treatment  in  this  type  is  very 
satisfactory.  Deafness  at  rare  intervals  follows  an  attack  of  mumps 
and  is  due  to  an  involvement  of  the  labyrinth.  This  condition  calls 
for  expert  otologic  treatment. 

Deaf  children  whose  condition  is  not  recognized  are  often  accused 
of  inattention  and  punished  when  they  are  slow  in  responding  when 
spoken  to.  They  make  slow  progress  in  school  and  are  considered 
stupid.  Many  such  children  suffer  from  defective  hearing  of  a  pro- 
nounced type  due  often  to  enlarged  tonsils  and  adenoids. 

600 


ACUTE    OTITIS  601 

The  management  in  these  cases  is  to  remove  the  adenoids  and 
tonsils.  When  rehef  is  not  afforded  by  operation,  the  child  should  be 
taken  to  an  aurist  for  a  careful  examination  as  to  the  condition  of  the 
ears  and  the  hearing  capacity. 

ACUTE  OTITIS 

Among  the  ailments  of  children  few  diseases  are  more  frequently 
encountered  than  catarrhal  or  purulent  otitis  media.  It  occurs  with 
great  frequency  in  the  hospital  athreptic  and  in  the  institution  infant. 
No  age  is  exempt.  I  have  seen  otitis  in  infants  of  a  few  weeks  of  age. 
In  well-nourished,  vigorous  older  children,  it  is,  with  but  few  excep- 
tions, a  secondary  infection.  In  poorly  nourished  athreptic  infants  it 
may  occur  without  other  evidence  of  illness.  I  have  repeatedly  found 
otitis  of  a  low  grade  in  athreptics  who  lacked  the  usual  signs  of  fever, 
discharge,  and  bulging  of  the  drum.  In  fact,  in  a  considerable  num- 
ber of  cases  the  otitis  was  first  discovered  at  autopsy. 

Types. — It  is  customary  to  divide  the  cases  into  two  primary  types: 
catarrhal  and  purulent.  Such  a  grouping  is  hardly  necessary,  as  most 
cases  of  the  purulent  type  if  seen  sufficiently  early  present  what  are 
described  as  catarrhal  symptoms.  If  the  infection  is  not  severe  it  sub- 
sides or  responds  to  treatment.  On  the  other  hand,  I  have  seen  cases 
in  which  the  ears  had  been  frequently  examined  and  in  which  the  in- 
flammation was  unquestionably  purulent  from  the  onset. 

Etiology. — Otitis  is  caused  by  the  invasion  of  bacteria  into  the 
middle  ear. 

In  the  atrophic  young  infant  the  low  systemic  resistance  and  the 
patulous  Eustachian  tube  account  for  the  ease  with  which  the  infec- 
tion reaches  the  middle  ear  and  becomes  operative.  In  older  children 
adenoids  and  enlarged  tonsils  comprise  the  chief  predisposing  etiologic 
factors.  Influenza,  scarlet  fever,  measles,  and  diphtheria  are  the  dis- 
eases most  frequently  accountable  for  otitis.  It  may  follow  any  infec- 
tion of  the  nose  or  throat;  thus  we  often  see  cases  associated  with  or 
following  rhinitis  and  tonsillitis.  If  a  generous  growth  of  adenoids 
exists  in  the  vault  of  a  throat  affected  by  any  one  of  the  above  diseases, 
the  chances  are  more  than  even  that  suppurative  otitis  will  develop. 

Among  a  series  of  72  private  cases  which  were  reported  several 
years  ago,  3  were  apparently  primary  in  that  the  condition  did  not 
follow  and  was  not  connected  with  any  previous  abnormal  state.  One 
case  followed  German  measles;  4,  scarlet  fever;  7,  measles;  and  58, 
influenza  or  catarrhal  colds. 

Bacteriology. — In  a  series  of  47  cases  in  which  bacteriologic  ex- 
aminations were  made,  the  results  were  as  follows: 

Streptococci  in  pure  culture 13 

Staphylococci 11 

Streptococci,  staphylococci,  and  pneumococci 12 

Streptococci,  staphylococci,  and  pneumococci.  .  .' 6 

Staphylococci,  pneumococci,  and  colon  bacilli 1 

Streptococci  and  staphylococci 2 

Pneumococci 2 


602  THE    PRACTICE    OF    PEDIATRICS 

The  streptococcus  suppKes  the  most  dangerous  form  of  infection, 
and  in  this  tj^pe  not  only  are  all  the  symptoms  more  severe,  but  there  is 
much  greater  danger  of  mastoid  involvement  and  secondary  sinus 
thrombosis. 

Symptoms. — Among  all  the  diseases  of  children  none  is  probably 
so  frequently  overlooked  as  otitis.  This  is  due  to  the  fact  that  the 
practitioner  invariabty  looks  for  pain  as  a  symptom  of  the  disease,  and 
this  has  been  the  teaching  of  the  books.  In  a  search  of  many  works  on 
otology  I  find  that  the  symptoms  as  laid  down  comprise  almost  ex- 
clusively the  evidences  of  pain, — earache, — the  pain  being  complained 
of  by  older  children,  or  manifested  in  the  very  young  by  vigorous  cry- 
ing, by  tossing  the  head  from  side  to  side,  by  head-rolling,  ear-tug- 
ging, crying  out  in  sleep,  disinclination  to  rest  the  head  on  the  affected 
side,  or  pain  upon  manipulation  of  the  ear.  In  short,  we  have  been 
taught  that  there  is  invariably  some  manifestation  of  pain  referable 
to  the  ear  or  the  adjacent  structures  in  all  cases  of  acute  otitis  in  in- 
fants and  young  children.  Such  symptoms  certainly  exist  in  a  mod- 
erate number  of  cases. 

The  most  interesting  feature,  however,  in  this  series  of  72  cases,  was 
the  absence  of  pain  or  locahzed  tenderness  on  manipulation  in  50  of 
the  cases,  or  69  per  cent.  Among  those  included  in  the  pain  group,  22 
in  number,  there  were  some  cases  which  perhaps  should  not  be  so  in- 
cluded, inasmuch  as  there  were  no  signs  of  pain,  as  we  generally  expect 
to  find  it.  The  group  included  those  who  were  very  restless,  who  slept 
poorly,  and  who  showed  evidence  of  the  relief  which  followed  incision 
of  the  drum  membrane,  so  that  it  was  fair  to  assume  that  the  source 
of  the  previous  discomfort  was  the  ear.  Had  we  depended  upon  the 
signs  of  pain  or  local  tenderness,  in  50  of  the  cases  a  diagnosis  of  otitis 
at  the  time  would  have  been  impossible.  Six  were  seen  in  consultation, 
because  of  the  unexplained,  continued  fever.  Nine  had  been  treated 
by  other  physicians  who  had  failed  to  discover  the  cause  of  the  con- 
tinued fever.  In  none  of  these  had  ear  involvement  been  suspected, 
because  of  the  absence  of  pain  and  localized  signs. 

Fever. — Among  the  72  private  cases  already  mentioned  in  well- 
nourished  children,  one  symptom  was  present  in  all — fever.  There 
was  nothing  particularly  characteristic  in  the  temperature  range.  In 
some  there  were  the  morning  drop  and  the  evening  rise.  In  others 
the  temperature  variations  were  inconstant.  With  but  few  exceptions 
the  otitis  developed  during  convalescence  from  an  acute  process  else- 
where, the  ear  involvement  being  suspected  because  of  a  persistent 
elevation  of  the  temperature  for  which  no  other  cause  could  be  dis- 
covered. The  fact  that  58  of  the  cases,  or  81.5  per  cent.,  occurred 
with  or  followed  non-specific  inflammatory  conditions  of  the  upper 
respiratory  tract,  such  as  tonsillitis,  grip,  and  catarrhal  colds,  empha- 
sizes the  necessity  for  frequent  aural  examinations  during  or  following 
such  disorders,  particularly  when  there  is  an  elevation  of  the  tempera- 
ture, which,  in  the  absence  of  definite  clinical  signs,  we  are  apt  possibly 
to  attribute  to  chronic  grip,  malaria,  typhoid  fever,  or  dentition. 


ACUTE    OTITIS  603 

Course. — In  a  small  number  of  cases  perforation  of  the  drum  occurs. 
I  have  known  the  drum  to  rupture  in  one  hour  from  the  onset  of  the  ear 
symptoms,  and  I  have  known  the  drum  to  remain  intact  with  pus  in  the 
middle  ear,  to  the  best  of  my  judgment,  for  ten  weeks.  In  the  average 
case,  after  a  free  opening  of  the  drum,  the  discharge  persists  from  ten 
to  twenty  days.  In  cases  due  to  streptococcus  infection  the  discharge 
is  always  more  prolonged. 

Prognosis. — The  prognosis  is  good  if  the  drum  is  freely  incised  and 
kept  open.  A  certain  small  percentage  of  cases  which  is  difficult  to 
determine  develop  mastoid  disease,  and  a  still  smaller  number  become 
complicated  by  sinus  thrombosis  and  jugular  bulb  involvement. 

The  drum  heals  most  readily.  In  numerous  cases  treated  by 
free  incision  I  have  found  the  drum  absolutely  normal  in  appearance 
within  three  or  four  weeks  after  the  discharge  ceased. 

Diagnosis. — Fever  without  apparent  cause  should  always  call  for  an 
examination  of  the  ears.  Earache  is  a  symptom  demanding  like 
attention. 

Otoscopic  examination  settles  the  diagnosis  and  is  the  means  of  con- 
firming or  refuting  symptoms  of  unsolved  fever  or  indefinite  pain. 

Complications. — The  most  frequently  encountered  complication  is 
mastoiditis  caused  by  extension  of  the  infective  process  to  the  mastoid 
cells.  The  mastoid  antrum  is  separated  from  the  middle  ear  by  a  very 
delicate  membrane.  In  many  cases  of  acute  otitis,  probably  in  all  cases 
showing  prolonged  discharge,  the  antrum  is  involved.  If,  within  a 
minute  or  two  after  mopping  out  the  canal,  there  is  a  free  discharge  into 
the  canal,  this  affords  strong  presumptive  evidence  that  the  antrum  is 
involved,  as  the  small  middle  ear  could  not  manufacture  pus  with  such 
rapidity. 

Prolapse  of  the  posterior  superior  wall  is  another  sign  of  mastoid 
involvement. 

The  continuation  of  high  fever  in  spite  of  free  aural  discharge  is 
indicative  of  mastoid  abscess. 

If  the  mastoiditis  exists,  there  may  be  swelling  behind  the  ear  or 
tenderness  on  firm  pressure  over  the  mastoid,  particularly  at  the  tip. 
Both  of  these  symptoms — pain  upon  pressure  and  swelling — may  fail 
us,  and  their  absence  is  not  to  be  considered  in  any  way  conclusive  evi- 
dence against  the  presence  of  mastoid  disease.  There  is  no  doubt  but 
that  in  many  cases  of  prolonged  aural  discharge  the  antrum  is  diseased 
and  supplies  a  large  part  of  the  pus.  The  deeper  cells  in  the  bone 
escape  infection. 

Treatment. — A  small  percentage  of  the  catarrhal  cases  in  which 
there  is  congestion  of  the  drum  without  bulging,  will  subside  under  irri- 
gation at  two-hour  intervals  with  normal  salt  solution  at  110°F.  One 
pint  should  be  used.  A  fountain-syringe  placed  at  an  elevation  of  three 
feet  above  the  child's  head  affords  the  best  means  of  irrigation. 

Regardless  of  the  age  or  condition,  a  bulging  drum  in  the  presence  of 
fever  calls  for  incision.  No  harm  is  done  to  the  ear  by  the  free  in- 
cision  properly  made,   while  much  harm   as  the  result  of   chronic 


604  THE    PRACTICE    OF    PEDIATRICS 

otitis  media  and   mastoid    disease  may  occur  when  the  incision  is 
delayed. 

Operative. — Every  practitioner  who  has  children  as  his  patients 
should  be  sufficiently  familiar  with  the  landmarks  of  the  normal  drum 
membrane  at  the  various  ages  of  early  life  to  differentiate  the  normal 
from  the  abnormal.  In  the  routine  examination  of  the  child,  in  all 
conditions  associated  with  angina  or  fever,  the  ear  should  be  included. 
In  quite  young  babies  an  otoscopic  examination  may  show  a  dull, 
whitish-appearing  drum  membrane  which,  on  a  superficial  examination 
of  the  case,  might  be  ignored.  In  all  cases,  particularly  at  this  age, 
when  the  drum  landmarks  are  indistinct,  a  cotton-pointed  probe 
should  be  brushed  over  the  surface,  thus  removing  the  epithelial  scales 
which  may  have  lodged  there,  then  perhaps  a  congested,  bulging 
membrane  may  be  revealed. 

Conditions  or  appearances  of  the  drum  membrane  which  require 
incision  are  often  difficult  of  recognition  by  those  not  skilled  in  otoscopy. 
When  the  drum  is  bulging,  deeply  congested  in  appearance,  with 
landmarks  indistinct,  an  incision  is  necessary,  and  should  be  made  in 
the  posterior  quadrant,  beginning  low  down  and  extending  upward 
through  Shrapnell's  membrane.  When  also  there  is  congestion  of 
the  drum  membrane  over  the  tubal  entrance,  and  when  the  congestion 
extends  toward  the  periphery,  producing  indistinct  landmarks  with- 
out bulging,  incision  is  indicated. 

Post-operative. — The  after-treatment  following  incision  consists  in 
syringing  the  ear  at  three-hour  intervals  with  8  ounces  of  a  1  :  10,000 
solution  of  bichlorid  of  mercury  for  three  or  four  days,  after  which  the 
syringing  may  usually  be  practised  at  intervals  of  from  four  to  five  hours 
until  the  drum  closes.  In  very  young  infants  if  the  bichlorid  causes  a 
dermatitis  at  the  meatus,  it  is  well  to  change  to  a  sterile  normal  salt 
solution,  using  the  same  quantity  of  fluid.  In  those  cases  in  which 
only  serum  is  present  at  the  time  of  operation,  closure  in  ten  days  may 
be  expected;  if,  however,  pus  is  present,  from  two  to  three  weeks  will 
be  required.  A  sudden  stopping  of  the  discharge  usually  means  that 
the  opening  in  the  drum  is  closed,  either  through  plugging  with 
thick  pus  or  because  of  too  early  healing.  In  either  event  a  reestab- 
lishment  of  the  discharge  is  required  by  removing  the  obstruction  or 
by  reincision.  The  chief  factors  in  prolonging  the  discharge  are  ade- 
noids and  a  lowered  state  of  physical  resistance.  After  the  syringing, 
the  ear  should  be  carefully  dried  with  absorbent  cotton.  For  purposes 
of  syringing  a  one-ounce  hard-rubber  ear  syringe  with  soft-rubber 
tip  answers  best.  If  this  is  not  obtainable,  a  douche-bag,  at  an  ele- 
vation of  not  more  than  three  feet  above  the  patient's  head,  may  be 
used.  The  douche-bag  sometimes  answers  better  for  those  who  are 
unskilled,  or  a  soft-rubber  bulb  syringe  of  a  capacity  of  one  or  two  ounces 
may  be  used.  The  small,  double-current  ear-irrigator  may  be  used  with 
advantage  for  the  reason  that  it  largely  prevents  wetting  the  patient. 
During  treatment  by  any  of  these  methods  the  child  rests  on  his 
back  with  his  hands  pinned  to  his  side  by  means  of  a  large  bath  towel, 


CHRONIC    SUPPURATIVE    OTITIS 


605 


while  a  pus  basin  is  held  under  the  ear  to  catch  the  flow  (Fig.  82) .     If 
the  nurse  can  have  an  assistant,  the  upright  position  may  be  used. 

Delayed  Resolution. — In  a  certain  number  of  cases  resolution  is 
delayed  and  the  discharge  continues.  In  such  cases  a  decided  aid  is 
furnished  by  the  use  of  stimulating  and  disinfectant  instillations. 
After  the  last  syringing  for  the  day  the  canal  should  be  dried  by  the 
use  of  a  -wick  of  absorbent  cotton.  Five  drops  of  the  following 
solution  are  then  to  be  instilled  into  the  ear: 

^    Pulv.  acidi  borici gr.  xxv 

Spts.  vini  rect., 
.  Aquae aa5ss 


k^^ 


Fig.  82. — ^Syringing  the   ear. 

McKernon,  of  New  York,  advises  the  use  of  a  15  per  cent,  solution 
of  argyrol  in  a  similar  manner. 


CHRONIC  SUPPURATIVE  OTITIS 

Not  infrequently  cases  come  under  our  care  in  which  there  is  a 
purulent  discharge  from  the  ears,  often  most  offensive,  with  a  history 
that  the  discharge  has  followed  measles,  scarlet  fever,  or  grip,  and  has 
continued  for  weeks  or  months.  Examination  may  show  a  perforation 
of  the  upper  portion  of  the  drum,  through  which  there  is  a  free  dis- 
charge, which,  however,  on  account  of  the  site  of  the  perforation,  is  not 
sufficient  to  drain  completely  the  middle-ear  cavity.  In  other  in- 
stances the  examination  may  disclose  only  a  small  perforation,  too  small 
for  effective  drainage. 


606  THE    PRACTICE    OF   PEDIATRICS 

Treatment. — In  either  case  incision  should  be  made  and  free  drain- 
age established.  The  ear  should  then  be  syringed  (Fig.  82)  at  least 
three  times  a  day  with  a  1 :  10,000  bichlorid  solution.  The  instillation 
of  a  solution  of  argyrol  and  boric  acid  (see  p.  605)  may  also  be  used  with 
decided  advantage.  In  cases  of  chronic  suppurative  otitis  it  is  well  to 
examine  for  adenoids,  as  these  growths  in  the  nasopharyngeal  vault 
help  to  keep  up  ear-discharge  indefinitely.  The  presence  of  dead  bone 
and  granulations  is  also  to  be  considered  in  the  chronic  suppurative 
cases.  When  the  presence  of  dead  bone  or  granulations  is  established, 
the  condition  calls  for  radical  procedures  by  a  skilled  otologist  in  order 
to  avoid  mastoid  and  intracranial  complications. 

In  long-standing  cases,  especially  those  due  to  staphylococcus  in- 
fection, the  administration  of  an  autogenous  vaccine  sometimes  is- 
attended  with  excellent  results. 

MASTOIDITIS 

Because  of  the  ease  with  which  pus  may  enter  the  mastoid  antrum 
the  complication  of  mastoiditis  is  of  frequent  occurrence  in  acute  aural 
diseases.  Streptococcal  infection  of  the  middle  ear  predisposes  to  mas- 
toid involvement.  Delay  in  incising  the  drum  and  establishing  free 
drainage  in  acute  otitis  is  also  a  factor  in  not  a  few  cases.  Finally,  as 
an  underlying  cause  of  mastoiditis  should  be  mentioned  the  child's 
lack  of  general  resistance  to  bacterial  infections. 

Symptoms. — Mastoid  disease  may  be  looked  for  in  all  cases  in  which 
an  elevation  of  the  temperature  continues  in  spite  of  free  discharge 
through  a  well-opened  drum.  Tenderness  on  pressure  is  a  valuable 
sign,  but  its  absence  does  not  preclude  mastoiditis. 

Prolapse  of  the  posterior  superior  wall  and  the  rapid  appearance  of 
pus  in  the  canal  after  thorough  cleaning  are  to  be  looked  upon  as  most 
important  symptoms. 

When  there  is  tumefaction  and  swelling  of  the  soft  parts  behind 
the  ear,  called  perimastoiditis,  the  mastoid  cells  and  antrum  will  almost 
invariably  be  found  involved.  In  about  10  per  cent,  of  the  cases  both 
mastoids  will  be  involved. 

Complications. — The  complications  are  sinus  thrombosis,  jugular 
involvement,  septic  meningitis,  and  pyemia.  I  have  seen  all  these 
most  serious  complications  in  not  a  few  cases,  and  have  cause  to  re- 
gard the  presence  of  pus  in  the  mastoid  cells  or  even  in  the  middle  ear 
in  children  as  a  matter  of  serious  import. 

Treatment. — The  radical  operation,  and  that  early,  is  the  only 
treatment  for  the  condition.  Children  have  unquestionably  recovered 
from  mastoid  disease  without  operation,  but  expectant  procedures  are 
fraught  with  great  danger  and  should  not  be  countenanced  if  the  child 
is  in  condition  to  admit  of  operation. 

SINUS  THROMBOSIS 

In  a  small  percentage  of  cases  of  mastoiditis  there  is  a  secondary 
infection  of  the  lateral  sinus. 


SINUS    THROMBOSIS  607 

Symptoms. — Sinus  involvement  will  usually  be  indicated  by  rapid 
and  wide  variations  in  the  temperature.  The  rise  is  very  sudden,  and 
may  reach  106°  F.  I  have  seen  a  rise  of  10  degrees  in  two  hours;  the 
fall  may  be  correspondingly  rapid,  and  a  peculiarity  of  the  temperature 
phenomena  in  sinus  disease  is  the  extent  of  the  fall.  I  have  repeat- 
edly known  the  fever  to  drop  to  96°F. 

A  confusing  and  misleading  circumstance  in  these  cases  may  be  the 
absence  of  signs  of  great  prostration.  When  the  temperature  is  high, 
the  child  appears  very  ill ;  when  the  fever  subsides,  the  patient  brightens, 
perhaps  plays,  and  is  interested  in  his  surroundings.  It  is  difficult  to 
reconcile  the  patient's  demeanor  with  so  grave  a  disease.  The  mis- 
leading behavior,  in  my  observation,  has  been  the  occasion  of  delaying 
operative  measures  until  such  means  proved  of  no  avail. 

Leukocytosis  and  a  high  polynuclear  count  are  usually  present.  I 
had  one  case,  however,  in  which  the  polynucleosis  was  not  above  60 
per  cent. 

Bacteremia  is  usually  present.  Its  absence,  however,  does  not  pre- 
clude sinus  disease. 

Treatment. — The  treatment  is  the  radical  operation,  witli  resection, 
if  necessary,  of  the  jugular  vein. 


XVI.  THE  TRANSMISSIBLE  DISEASES 

In  this  division  of  diseases  are  included  those  which  may  be  trans- 
mitted from  the  diseased  to  the  unprotected  individual. 

Diseases  TVhich  May  be  Transmitted  Through  Association. — Syphilis, 
diphtheria,  gonorrhea,  stomatitis,  tuberculosis,  pneumonia,  scarlet 
fever,  measles,  German  measles,  mumps,  smallpox,  chicken-pox,  per- 
tussis, poliomyelitis,  meningitis,  acute  cerebrospinal  meningitis,  plague, 
typhus,  influenza. 

Diseases  Which  May  he  Transmitted  Through  an  Intermediary. — 
Gonorrhea,  typhoid  fever,  malaria,  yellow  fever,  tuberculosis,  cholera, 
plague,  stomatitis,  typhoid  fever,  scarlet  fever,  diphtheria,  measles, 
chicken-pox,  pertussis,  syphilis,  typhus  and  poliomyelitis. 

It  will  be  observed  that  some  of  the  foregoing  diseases  are  trans- 
missible in  more  than  one  way. 

Syphilis,  in  addition  to  being  transmissible  through  association, 
is  transmissible  by  inheritance. 

Gonorrhea  is  transmissible  through  association  and  through  inter- 
mediary objects.  That  the  latter  mode  of  conveyance  is  common  is 
absolutely  proved  by  the  spread  of  the  disease  in  institutions  and  hos- 
pitals, through  the  use  of  the  thermometer  or  at  the  hands  of  attendants. 

Among  the  diseases  grouped  as  transmissible  through  association, 
in  which  such  transmission  is  eminently  a  feature  of  the  disease,  are 
those  that  usually  have  been  designated  as  contagious,  e.  g.,  scarlet 
fever,  diphtheria,  measles,  German  measles,  mumps,  smallpox,  chicken- 
pox,  pertussis  and  poliomyelitis. 

Among  the  diseases  transmissible  by  intermediary  means,  gonor- 
rhea has  been  referred  to. 

Typhoid  fever  is  usually  water-borne  or  food-borne  by  flies.  Ma- 
laria and  yellow  fever  are  transmitted  by  the  mosquito. 

Cholera  is  usually  a  water-borne  disease. 

Plague  may  be  transmitted  through  any  intermediary  which  has 
been  in  contact  with  the  infected  subject. 

Stomatitis,  a  comparatively  insignificant  disease,  may  be  trans- 
mitted through  nipples,  pacifiers,  or  toys  that  have  been  in  the  mouth. 

There  is  quite  an  unanimity  of  opinion  that  scarlet  fever,  diphthe- 
ria, measles,  chicken-pox,  mumps,  and  smallpox  may  be  transmitted 
from  the  diseased  to  the  unprotected  individual  through  the  agency  of 
an  intermediary  person  or  object.  My  own  observation  corroborates 
this  view.  At  the  same  time  I  am  sure  that  such  transmission  is  less 
frequent  than  is  generally  supposed. 

The  usual  means  is  through  association  with  an  individual  who  has 
the  disease,  perhaps  in  so  mild  a  manner  that  it  has  not  been  recognized. 

608 


VARICELLA    (CHICKEN-POX)  609 

This  is  particularly  the  case  with  diphtheria,  scarlet-fever  and  polio- 
myelitis. 

These  diseases,  viz.,  scarlet  fever,  diphtheria,  measles,  chicken-pox, 
pertussis,  German  measles,  poliomyelitis  and  mumps  have  another 
feature  in  common.  They  may  be  extremely  severe,  or  so  mild  that  the 
case  is  not  recognized,  and  the  patient  associates  as  usual  with  his  fel- 
lows. It  is  to  these  mild  cases  that  the  spread  of  the  disease  is  due 
rather  than  to  a  transference  of  the  contagium  through  unusual 
channels. 

It  has  been  estimated  that  1  per  cent,  of  children  in  cities  have 
viable  diphtheria  bacilli  in  their  throats. 

Scarlet  fever,  because  of  the  possible  variation  of  its  course  and  the 
indefinite  rash,  is  overlooked  more  frequently  than  any  other  of  the 
diseases  of  this  class.  It  is  not  at  all  unusual  for  school  inspectors  to 
find  children,  with  active  scarlet-fever  desquamation,  in  attendance  at 
schools.  The  abortive  non-paralytic  cases  of  poliomyelitis  are 
unquestionably  the  chief  agency  in  the  transmission  of  this  disease. 

I  have  seen  a  case  of  chicken-pox  in  which  there  were  but  five 
vesicles  without  other  sign  of  illness,  and  patients  with  unquestionable 
pertussis  who  never  whooped. 

The  last-mentioned  group  are  referred  to  in  the  chapters  which 
immediately  follow.  For  reasons  of  greater  convenience  some  of  the 
transmissible  diseases  are  described  elsewhere. 

CARE  TO  BE  EXERCISED  BY  THE  PHYSICIAN  IN  VISITING  INFECTIOUS 
AND  CONTAGIOUS  DISEASES 

Physicians  in  attendance  upon  contagious  diseases,  particularly 
diphtheria  and  scarlet  fever,  should  exercise  reasonable  care  in  their 
association  with  other  patients.  The  coat  should  be  removed  and 
shirt-sleeves  turned  up  to  the  elbows.  A  gown,  or  a  sheet  suitably 
adjusted  with  safety  pins,  should  protect  the  clothing. 

After  leaving  the  patient  the  physician  should  wash  his  hands  with 
hot  water  and  soap, 

VARICELLA  (CHICKEN-POX) 

Chicken-pox  belongs  to  the  transmissible  diseases,  and  is  usually 
transmitted  by  association  contact,  rarely  through  an  intermediary. 
The  contagium  of  varicella  is  present  in  the  fluid  contents  of  the  eruptive 
vesicles,  and  also  in  the  crusts  resulting  from  the  drying  of  the  vesicular 
contents.  Consequently  the  period  of  transmissible  infection  persists 
as  long  as  any  crusts  remain  on  the  skin.  The  exact  nature  of  the 
specific  etiologic  factor  of  this  disease  is  still  unknown. 

Incubation. — The  period  of  incubation  is  rarely  less  than  eighteen 
days  or  longer  than  twenty-five  days.  In  the  majority  of  my  cases  it 
has  ranged  between  twenty  and  twenty-five  days. 

Symptoms. — Prodromal  symptoms  are  rarely  of  sufficient  severity 
to  warrant  complaint  or  give  evidence  of  illness  on  the  part  of  the 
39 


610  THE    PRACTICE    OF    PEDIATRICS 

child.     In  severe  cases  there  may  be  sHght  temperature  and  muscle 

soreness. 

The  temperature  rarely  goes  above  102°F.,  usually  not  over  100°F. 

The  Rash. — The  eruption  is  usually  the  first  important  sign  of  the 
disease.  The  back  and  abdomen  are  the  sites  ordinarily  involved  early. 
The  rash  may  appear  on  any  portion  of  the  body.  It  occurs  abun- 
dantly on  the  scalp.     Usually  there  are  a  few  spots  in  the  mouth. 

Character  of  Rash. — Not  infrequently  from  the  onset  it  is  distinctly 
vesicular,  without  any  associated  skin  inflammation,  resembling  drops 
of  water  that  may  have  been  sprinkled  carelessly  over  the  skin  surface. 
More  frequently  the  rash  consists  of  macules,  then  papules,  and  later 
vesicles  resting  on  well-defined  red  areolae.  At  first  the  vesicles  con- 
tain clear  fluid  and  vary  in  size  from  mere  points,  scarcely  discernible 


Fig.  83. — Deep  ulceration  in  case  of  dermatitis  gangrenosa  infantum  following 

chicken-pox. 

to  the  naked  eye,  to  lesions  3^^  inch  in  diameter.  In  a  few  hours  the 
serum  becomes  cloudy  and  purulent.  In  from  twenty-four  to  seventy- 
two  hours  the  fluid  is  absorbed,  leaving  the  erupted  area  slightly  um- 
bihcated,  so  that  on  further  drying  this  forms  a  crust  or  scab.  These 
crusts  fall  off  in  from  one  to  three  weeks,  leaving  a  distinctly  reddish 
skin  area,  at  the  site  of  which  there  is  sometimes  a  temporary  scar. 
The  rash  varies  greatly  in  its  intensity.  Most  of  the  lesions  do  not 
go  through  the  characteristic  stage  just  mentioned,  and  many  do  not 
go  beyond  the  papular  stage.  All  stages  of  the  eruption  may  be  seen 
at  one  time  in  any  well-marked  case,  for  the  reason  that  the  rash  ap- 
pears in  successive  crops,  of  which  there  are  usually  three,  although 
there  may  be  more.  The  first  crop  may  be  in  the  scabbing  stage  when 
the  third  or  a  later  crop  appears.  The  amount  of  rash  is  extremely 
variable.  In  one  of  my  cases  there  were  but  three  vesicles.  In  three 
others,  all  institution  cases,  so  severe  and  extensive  was  the  rash  that  it 
resulted  in  a  gangrenous  dermatitis  consisting  of  clearly  punched-out 
ulcers.  The  gangrenous  area  coalesced,  with  destruction  of  large 
areas  of  the  skin  surface.     These  three  cases  were  all  fatal. 

Complications. — Erysipelas  was  a  complication  in  two  cases;  gan- 
grenous dermatitis  in  three.  Nephritis,  although  rare,  may  develop. 
One  of  the  worst  cases  of  acute  glomerular  nephritis  which  I  have  had 
occasion  to  treat  occurred  as  a  sequel  of  chicken-pox.     Furunculosia 


MUMPS  611 

due  to  infection  by  scratching  is  a  quite  frequent  complication  in  chil- 
dren's asylums. 

Duration. — The  duration  of  an  attack,  from  the  beginning  of  the 
period  of  eruption  until  the  skin  clears,  is  about  three  weeks,  but  may 
be  longer.     In  mild  cases  the  skin  may  become  clear  in  two  weeks. 

Quarantine. — The  child  should  be  kept  in  quarantine  and  not  al- 
lowed to  come  in  contact  with  unprotected  children  until  three  weeks 
have  elapsed,  or  until  the  skin  is  free  from  crusts. 

Prognosis. — The  prognosis  is  good.  It  is  very  unusual  for  the 
most  delicate  child  to  succumb  to  the  disease.  The  institution  infants 
who  developed  gangrenous  dermatitis  (Fig.  83)  were  the  only  fatal 
cases  to  come  under  my  observation. 

Treatment. — Chicken-pox  is  a  disease  for  which  very  little  treat- 
ment is  required.  During  the  eruptive  period,  and  until  the  period  of 
vesiculation  is  passed  and  the  crusts  have  formed,  the  child  should  be 
kept  in  bed. 

During  the  stage  of  active  eruption  the  tub-bath  should  be  omitted. 
Instead,  gentle  sponging  with  a  tepid  solution  of  boric  acid — two  heap- 
ing tablespoonfuls  of  boric  acid  to  one-half  gallon  of  boiled  water — will 
answer  the  purpose  of  cleanliness  for  a  few  days.  After  the  daily 
sponging,  and  several  times  during  the  day,  the  areas  affected  should  be 
anointed  w^ith  a  boric-acid  ointment  made  with  cold-cream  as  follows: 

I^     Mentholis gr.  x 

Pulveris  acidi  borici gr.  c 

Unguenti  aquae  rosie Bij 

The  ointment  effectually  relieves  the  itching,  and  doubtless  is  of 
value  in  preventing  local  skin  infection  through  scratching.  An  equally 
effective  remedy,  but  one  less  agreeable  for  domestic  use,  is  a  lotion  of 
5  per  cent,  ichthyol  and  sterilized  olive  oil.  This  is  to  be  applied  to 
the  entire  body  twice  daily  after  the  bath.  Objections  to  its  use  are 
the  odor  and  the  staining  of  the  clothing  and  bed-linen.  Permanent 
scars  at  the  site  of  the  vesicles  are  so  rarely  seen  that  no  special  precau- 
tions are  required  on  this  account. 

MUMPS  (EPIDEMIC  OR  SPECIFIC  PAROTITIS) 

Mumps  is  a  specific  infection  of  the  parotid  glands. 

Cocci  have  been  isolated  from  the  inflamed  parotid  gland  in  cases 
of  mumps,  but  their  specificity  has  never  been  proved.  More  recent 
studies  point  to  a  filtrate  virus,  as  the  probable  cause  of  the  disease 
(Wollstein).  The  exact  nature  of  the  virus  has  not  yet  been  deter- 
mined. 

Mumps  affects  chiefly  the  runabout  and  school-children.  Infants 
and  very  young  children  rarely  have  the  disease. 

Transmission. — The  disease  may  be  conveyed  by  direct  contact 
or  through  intermediary  individuals,  books,  toys,  or  clothing. 

Incubation. — The  period  of  incubation  is  long — from  three  to  four 
weeks. 


612  THE    PRACTICE    OF    PEDIATRICS 

Duration. — The  duration  of  the  disease  from  the  commencement 
of  the  sweUing  until  it  has  completely  subsided  is  from  ten  days  to 
two  weeks. 

Quarantine  should  be  maintained  until  the  swelling  has  entirely 
subsided. 

Pathology. — As  the  great  majority  of  cases  recover,  it  has  been 
difficult  to  study  the  pathology  of  the  disease.  The  pathologic  changes 
that  are  known  to  occur  are  ordinarily  limited  to  the  salivary  glands. 
There  is  edema  and  cellular  infiltration  of  the  connective  tissue  around 
the  ducts  and  between  the  acini,  while  the  glandular  epithelium  is 
often  swollen  and  cloudy.  The  infiltration  is  most  marked  around 
the  secretion  ducts. 

When  mumps  affects  the  testis,  the  inflammation  assumes  a  paren- 
chymatous form,  and  when  the  epithelial  degeneration  in  the  tubules 
is  severe,  atrophic  changes  in  this  gland  may  follow.  Occasionally  the 
orchitis  is  accompanied  by  urethritis,  edema  of  the  scrotum,  and 
inguinal  adenitis. 

Ovaritis  and  mastitis  complicating  mumps  have  been  observed. 
Acute  pancreatitis  has  been  reported. 

Symptoms. — Usually  one  gland  is  affected  at  first,  and  the  gland 
first  affected  is  usually  the  one  most  prominently  involved,  the 
second  gland  rarely  reaching  the  size  of  the  first  and  subsiding  much 
sooner.  In  some  cases,  three  or  four  days  intervene  before  the  second 
gland  shows  the  characteristic  swelling.  The  submaxillary  glands  may 
be  involved  in  the  process,  but  usually  escape.  In  one  of  my  patients 
the  submaxillary  glands  alone  were  involved.  In  a  very  recent  case 
in  a  child  three  years  of  age  both  parotids  and  submaxillary  glands 
and  the  sublingual  gland  showed  massive  involvement. 

Involvement  of  other  salivary  glands  than  the  parotid  is  more  fre- 
quent during  cold  weather. 

There  may  be  prodromal  symptoms  of  fever  and  languor.  Diffi- 
culty is  experienced  by  the  patient  in  working  the  jaws.  Not  infre- 
quently there  are  sharp  neuralgic  pains  and  pains  referred  to  the  ear. 
An  elevation  of  the  temperature  is  usual  during  the  acute  stage,  al- 
though this  may  not  exceed  100°F.  In  most  instances  it  will  not  ex- 
ceed 102°F.  If  the  glands  are  involved  at  two  or  three  days'  interval, 
there  may  be  two  distinct  rises  in  temperature.  The  temperature  is 
rarely  sufficiently  high  to  demand  special  streatment. 

Diagnosis  and  Differential  Diagnosis. — The  patient  presents  a 
characteristic  picture,  the  face  taking  on  a  rotund,  rather  ludicrous 
appearance,  produced  by  no  other  malady.  Acute  adenitis  of  the 
lymphatic  glands  at  the  angle  of  the  jaw  is  most  frequently  mistaken 
for  mumps.     Mumps,  on  the  other  hand,  is  not  mistaken  for  adenitis. 

In  history  taking,  not  infrequently  one  is  told  that  the  child  has  had 
two  or  three  attacks  of  mumps,  which  means  that  the  child  has  had 
perhaps  one  attack  of  mumps  and  several  of  acute  adenitis.  In  mumps 
the  swelling,  by  involving  the  parotid,  which  it  will  be  remembered  is 
in  front  of  and  below  the  ear  (Fig.  84),  displaces  the  lobe  upward  and 


MUMPS 


613 


outward  and  completely  fills  the  depression  posterior  to  the  lobe.  In 
adenitis  (Fig.  48)  there  is  usually  a  well-marked  depression  between  the 
sweUing  and  the  adjoining  parotid. 

Complications. — Complications  in  mumps  are  exceedingly  rare  be- 
fore puberty.  Orchitis  may  occur  in  boys  and  ovaritis  in  girls,  but  only 
very  exceptionally  if  the  patient  is  kept  in  bed.  Infection  of  the  paro- 
tid other  than  that  produced  by  the  specific  poison  of  rnumps  is  ex- 
tremely rare.  Abscess  as  a  complication  due  to  a  mixed  infection  has 
been  reported.  Nephritis  is  an  occasional  complication.  I  have  seen 
one  such  case  in  a  boy  two  years  of  age.     I  have  never  observed  corn- 


Fig.    84. — Mumps. 


plicating  pericarditis,  endocarditis,  or  pancreatitis,  although  such  com- 
plications have  been  reported. 

Prognosis. — The  prognosis  is  good.  I  have  never  known  a  second 
attack,  a  relapse,  or  a  death  from  the  disease. 

Treatment. — During  an  attack  the  child  should  be  kept  in  bed  until 
the  temperature  is  normal,  and  should  remain  in  the  house  until  the^ 
swelling  has  entirely  subsided.  He  should  receive  a  reduced  diet  of 
broths,  gruels,  and  milk,  as  in  any  illness  with  fever.  Fruits  and  acids 
should  not  be  given  because  of  the  discomfort  they  occasion.  Unless 
the  bowels  move  daily  without  assistance,  citrate  of  magnesia  or  a 
Seidlitz  powder  should  be  given. 

Warm  applications  at  times  relieve  the  pressure  and  discomfort. 
Flannel  moistened  with  warm  camphorated  oil  and  bound  to  the  parts 
has  been  acceptable  to  many  patients. 


614  THE    PRACTICE    OF   PEDIATRICS 

WHOOPING-COUGH  (PERTUSSIS) 

As  an  infectious  disease  of  importance,  pertussis  may  be  classed 
with  diphtheria  and  scarlet  fever.  It  is  probably  the  cause  of  more 
deaths  today  than  is  any  other  infectious  disease.  It  does  not  kill 
directly  through  the  means  of  a  specific  poison,  as  do  diphtheria  and 
scarlatina,  but  on  account  of  its  prolonged  course  and  its  many  compli- 
cations is  equally  effective  as  a  Hfe-destroyer. 

History. — Whooping-cough  has  existed  from  early  times,  under 
such  names  as  "tussis  perennis,"  "tussis  infantum,"  ''chink  cough," 
"chine-cough,"  and  "king's  cough."  In  a  treatise  published  in  1773 
Wilham  Butter,  of  Edinburgh,  aptly  describes  "kinkcough"  as  "a 
quick  and  numerous  succession  of  violent,  short  coughs  followed  by  a 
long,  strait,  and  generally  shrill  inspiration,  which  coughs  and  inspira- 
tion are  repeated  without  intermission  for  many  seconds  or  often  some 
minutes,  and  often  terminate  in  the  vomiting  of  phlegm."  Robert 
Watt,  writing  in  1813,  states  that  ''next  to  the  small-pox  formerly,  and 
the  measles  now,  chincough  is  the  most  fatal  disease  to  which  children 
are  liable." 

The  seat  of  the  affection  was  variously  placed  by  the  early  writers 
in  the  nervous  system,  in  the  digestive  organs,  and  in  different  portions 
of  the  respiratory  tract.  Butter  believed  that  "miasms  generated  in 
the  guts,  act  on  the  nerves"  and  "increase  irritability."  Further 
information  is  proffered  in  statements  that  "measles  render  the  kink- 
cough  very  dangerous;"  "smallpox  either  cures  or  palliates;"  and  that 
"hemlock  cures  the  kinkcough  in  a  week."  A  critic  of  the  hemlock 
therapy  ironically  recalls  that  "the  flesh  of  fryed  mice  .  .  .  has 
been  in  vogue  as  a  specific."  Certain  it  is  that  even  in  very  recent 
years  no  disease  has  been  treated  by  remedies  of  wider  diversity. 
Partial  explanation  of  this  fact  undoubtedly  rests  upon  the  frequent 
association  of  whooping-cough  with  other  diseases,  as  well  as  upon  the 
varying  therapeutic  requirements  of  its  more  common  complications. 

Bacteriology. — The  bacillus  described  by  Bordet  and  Gengou  in 
1906  is  at  present  generally  accepted  as  the  probable  cause  of  pertussis. 
The  bacillus  is  a  short,  ovoid,  polex,  regular,  non-motile  rod,  which 
doe.s  not  stain  by  Gram's  method.  It  is  best  isolated  upon  plates  of 
potato-agar  mixed  with  rabbit's  blood,  as  described  by  Bordet  and 
Gengou,  but  later  generations  grow  readily  upon  plain  agar.  The 
bacillus  is  present  in  the  sputum  in  enormous  numbers,  and  almost  in 
pure  cultures  on  the  first  two  or  three  days  after  the  onset  of  the  whoop, 
and  it  may  be  found  several  days  before  the  spasmodic  stage  begins 
(Wollstein).  At  the  end  of  the  first  week  of  this  stage,  however,  other 
bacteria,  such  as  pneumococci  and  staphylococci,  have  usually  become 
so  numerous  that  isolation  of  the  bacillus  is  impossible.  Agglutina- 
tion reactions  with  the  patient's  serum  are  irregular  and  unsatisfactory. 
Complement  fixation  tests  have  been  reported  positive,  but  they  are 
not  regularly  so. 

Jochmann  and  Krause  found  the  influenza  bacillus  in  the  sputum  of 
pertussis  patients  in  100  per  cent,  of  the  cases  they  studied.     It  may  be 


WHOOPING-COUGH    (PERTUSSIs)  615 

present  there  before  the  whoop  develops  (Wollstein),  and  it  may  remain 
for  a  period  of  six  months  after  the  attack  has  ceased  (Davis),  thus 
making  of  these  patients  influenza-bacillus  carriers. 

In  children  who  have  died  during  the  spasmodic  stage  of  an  attack 
of  pertussis  the  Bordet-Gengou  bacillus  has  been  found  in  the  heart's 
blood  and  also  in  the  lungs,  where  Bacillus  influenzae  is  usually  present 
as  well. 

Pathology. — There  is  very  little  characteristic  pathologic  change  in 
pertussis.  There  is  an  inflammation  and  infiltration  of  the  raucous 
membrane  of  the  larynx  and  upper  trachea,  which  is  doubtless  the  seat 
of  the  specific  infection.  Mallory  claims  that  the  specific  lesion  is  the 
presence  of  B.  pertussis  between  the  cilia  of  the  epithelial  cells  of  the 
trachea  and  bronchi. 

Transmission. — Transmission,  as  with  most  of  the  communicable 
diseases,  is  by  means  of  direct  contact.  That  pertussis  may  be  con- 
veyed through  the  medium  of  clothing,  a  book,  a  toy,  or  a  second  person 
is  exceedingly  doubtful. 

Extreme  youth  offers  no  protection,  as  in  the  case  of  scarlet  fever 
or  diphtheria. 

Infective  Period. — The  disease  may  be  transmitted  from  the  begin- 
ning of  the  catarrhal  stage.  The  duration  of  the  period  of  infection  is 
not  known.  It  probably  continues  in  the  average  case  until  the  child 
ceases  to  whoop. 

When  pertussis  breaks  out  in  a  school  or  in  an  institution  for  chil- 
dren, prevention  of  an  epidemic  is  practically  impossible,  because  the 
disease  is  infectious  during  the  early  catarrhal  stage,  which  lasts  from 
one  to  two  weeks.  During  this  time  the  only  symptom  is  a  cough  and 
perhaps  a  slight  degree  of  bronchitis,  such  as  exists  with  a  common  cold.^ 

Susceptibility. — The  previous  state  of  health  appears  to  exert  no 
influence  upon  the  patient's  susceptibility.  The  strong  and  the  deli- 
cate are  alike  predisposed  to  infection.  The  very  young  and  the  adult 
are  less  liable  to  take  the  disease  than  are  children  between  the  fourth 
month  and  the  third  year.  This  period  is  the  most  susceptible  time  of 
life.  Cases  have  been  reported  in  children  one  week  old.  Any  other 
concurrent  infectious  disease  exerts  no  influence  upon  the  course  of  the 
pertussis.  The  theory  has  been  advanced  that  the  advent  of  diph- 
theria or  scarlet  fever  during  an  attack  of  pertussis  shortened  and 
modified  the  course  of  the  disease.  My  experience  does  not  corrobo- 
rate this  behef.  Other  affections  which  occur  during  an  attack  simply 
increase  the  burden  to  be  borne  by  the  patient.  The  largest  number  of 
cases  develop  during  the  warmer  months — from  May  to  November. 
This  circumstance  may  be  accounted  for  in  part  by  the  fact  that  during 
the  warm  period  of  the  year  the  infected  child  comes  more  frequently 
in  contact  with  unprotected  neighbors.  The  same  circumstance,  how- 
ever, tends  to  disprove  that  catarrhal  affections  of  the  respiratory  tract 
predispose  to  the  disease,  since  respiratory  affections  in  the  young  dur- 
ing the  warmer  months  are  notably  rare.  The  normal  healthy  mucous 
membrane  offers  no  greater  resistance  to  pertussis  than  does  that  which 


616  THE    PRACTICE    OF    PEDIATRICS 

is  affected  by  disease.  In  the  early  stages  of  pertussis  there  is  not 
simply  a  bronchitis,  but  a  catarrhal  process  due  to  a  specific  infection. 

Interesting  observations  relative  to  susceptibility  to  measles  and 
pertussis  were  made  by  Biedert.  After  a  lapse  of  sixteen  years  both 
these  diseases  broke  out  in  a  German  village  at  about  the  same  time. 
There  were  401  children  in  the  village  under  fourteen  years  of  age. 
These  children  had  never  been  far  from  home,  and  not  one  of  them 
had  had  either  measles  or  pertussis.  Of  this  number,  344  became  ill 
with  measles  and  366  with  pertussis,  340  having  both  diseases  at  once. 
The  susceptibility  of  these  unprotected  children  to  pertussis  was, 
therefore,  95.5  per  cent.;  to  measles,  85.8  per  cent.  Of  those  who 
escaped  pertussis,  7  were  under  five  years  of  age,  4  between  five  and 
ten  years,  and  9  between  ten  and  fourteen  years. 

Incubation. — The  period  of  incubation  is  difficult  to  determine. 
It  seems  to  range  from  seven  to  fourteen  days. 

Symptoms. — At  the  outset  the  cough  may  be  short,  hard,  and  of  a 
paroxysmal  nature.  Usually,  however,  the  cough  is  in  no  way  char- 
acteristic and  does  not  differ  from  that  which  accompanies  bronchitis 
or  tracheitis.  Instead  of  improving  under  treatment,  this  symptom 
becomes  more  severe  and  more  frequent.  The  child  coughs  more  at 
night,  usually,  than  during  the  day.  In  a  week  or  ten  days,  rarely  less 
than  a  week,  the  characteristic  whoop  occurs. 

Complications. — The  complications  of  pertussis  are  many,  and 
account  for  the  fact  that  the  disease  is  so  destructive  to  life.  The 
mortality  of  pertussis  is  generally  estimated  at  4  to  6  per  cent.  That  it 
is  actually  much  higher  is  well  known  to  every  one  who  has  seen  much  of 
the  disease.  The  most  fatal  complication  in  winter  is  bronchopneu- 
monia; in  summer,  gastro-enteric  disease.  Convulsions  are  not  an 
infrequent  complication,  and  may  be  fatal.  Malnutrition  often  follows 
a  severe  attack  in  delicate,  bottle-fed  children,  thus  paving  the  way  for 
intercurrent  disease.  Tuberculosis  not  infrequently  follows  a  pro- 
longed attack  of  pertussis.  Blindness,  deafness,  and  motor  disturb- 
ances have  all  been  observed  during  attacks  of  pertussis,  and  have  been 
followed  by  complete  recovery.  These  cases  may  be  explained  as 
follows:  During  a  severe  paroxysm  the  cerebral  circulation  is  greatly 
disturbed,  and  as  a  result  of  a  moderate  congestion  or  venous  hyperemia, 
there  is  a  disturbance  of  nutrition  in  certain  portions  of  the  brain. 
On  the  cessation  of  the  paroxysm  these  symptoms  all  disappear. 

Diagnosis. — The  diagnosis  of  pertussis  is  most  difficult  in  the  early 
stages,  before  the  whoop  or  convulsive  paroxysm  develops.  Even  a 
spasmodic  cough  does  not  always  mean  a  developing  pertussis. 

In  rachitic  children,  and  in  those  in  whom  the  nervous  element  is 
prominent,  the  cough  of  an  ordinary  cold  is  often  of  a  decidedly 
paroxysmal  character,  especially  when  there  is  an  acute  or  subacute 
laryngitis. 

The  cough,  however,  if  more  troublesome  at  night,  favors  a  diagno- 
sis of  pertussis.  If  the  diagnosis  is  correct,  the  cough  grows  steadily 
worse  and  resists  the  usual  treatment  of  colds. 


WHOOPING-COUGH    (PERTUSSIs)  617 

The  mild  cases  are  also  difficult  of  diagnosis. 

Illustrative  Cases. — Recently  two  patients,  aged  eight  and  ten  years  respec- 
tively, went  through  an  attack  of  pertussis  with  but  two  or  three  severe  paroxysmal 
coughing  attacks. 

Two  other  cases  seen  in  private  practice  also  show  how  mild  may  be  the 
course.  The  patients,  brother  and  sister,  aged  six  and  eight  years  respectively, 
commenced  coughing  about  ten  days  after  exposure.  The  cough  was  paroxysmal, 
with  from  three  to  five  seizures  in  twenty-four  hours.  The  boy  whooped  only  three 
times  during  the  entire  course  of  the  disease;  the  girl  did  not  whoop  at  all.  Vomit- 
ing never  occurred  with  a  paroxysm.  Both  patients  coughed  for  six  weeks.  They 
had  neither  adenoids  nor  bronchitis. 

Often  the  very  young  and  the  very  delicate  do  not  whoop,  even  dur- 
ing a  severe  attack.  Among  the  severe  cases  convulsions  and  hemor- 
rhage from  the  nose,  ears,  and  eyes  are  seen  from  time  to  time.  A  very 
severe  seizure  in  a  girl  nine  months  old  was  followed  by  small  extra- 
vasations of  blood  into  the  skin  of  the  entire  body. 

Differential  Diagnosis. — In  all  cases  of  severe  cough  of  uncertain 
origin  the  nasopharyngeal  vault  must  be  examined  for  adenoid  growths. 
In  young  children  this  can  be  properly  done  only  by  the  use  of  the  index- 
finger. 

The  presence  of  a  persistent  cough  with  a  paroxysmal  tendency,  in 
the  absence  of  local  respiratory  irritation  of  any  nature,  is  very  sug- 
gestive in  a  suspected  case. 

Prognosis. — Pertussis  in  children  under  eighteen  months  of  age 
must  ever  be  regarded  in  a  serious  light.  Delicate  and  rachitic  chil- 
dren should  be  carefully  guarded  against  the  disease.  Bronchopneu- 
monia and  gastro-enteric  troubles  are  the  most  frequent  complications 
among  this  class  of  children.  The  majority  of  healthy  children 
over  eighteen  months  of  age  bear  whooping  cough  without  great 
inconvenience. 

Treatment. — A  wide  experience  in  the  use  of  pertussis  vaccine  places 
this  method  of  treatment  in  the  front  rank  of  the  remedies.  As 
a  single  remedial  measure  the  vaccine  furnished  better  results  as  regards 
relieving  the  symptoms  and  shortening  the  disease  than  any  other 
form  of  treatment.  As  with  all  new  therapeutic  measures  one  must 
learn  by  observation  in  a  considerable  number  of  cases  how  to  apply 
the  remedy.  Our  best  results  have  been  obtained  where  the  following 
dosage  and  procedure  was  carried  out.  Four  injections  were  given 
with  one  day  intervening  between  each  as  follows: 

1st  =  1  Billion 
2d  -  2  Billion 
3d  =  4  Billion 
4th  =  6  Billion 

There  were  29  cases  treated  in  private  practice. 

In  2  cases  the  results  were  entirely  negative,  no  apparent  effects 
were  noticeable.  In  these  we  resorted  to  the  use  of  drugs.  In 
27  cases  the  results  were  very  striking.  A  complete  cessation  of  the 
paroxysms  resulted  in  from  one  to  four  weeks.  A  decided  improve- 
ment was  often  noticed  after  the  second  or  third  injection.     If  after 


618  THE    PRACTICE    OF    PEDIATRICS 

the  above  method  there  is  Httle  or  no  improvement  or  if  there  is  a 
recurrence  of  the  paroxysms  two  more  injections  of  6  BilHon  each 
are  given  at  an  interval  of  forty-eight  hours. 

Drug  Treatment, — The  use  of  drugs  in  whooping  cough  has  always 
been  more  or  less  of  a  disappointment.  We  have  been  able  in  most 
cases  to  supply  a  certain  amount  of  relief.  The  illness  may  be  made 
easier  for  the  patient  to  bear,  which  of  course  is  important.  By  the 
use  of  drugs  the  paroxysms  may  be  lessened  in  number  and  severity. 

My  best  results  have  been  obtained  in  the  use  of  antipyrin  and 
bromid  of  soda  in   combination   as   follows: 

For  a  child  eight  months  of  age,  Yi  grain  of  antipyrin  with  2  grains 
of  bromid  of  soda  are  given  at  two-hour  intervals — 6  doses  in  twenty- 
four  hours ;  for  a  child  of  fifteen  months,  1  grain  of  antipyrin  and  2}''^ 
grains  of  bromid  of  soda  at  two-hour  intervals — 6  doses  in  twenty-four 
hours;  from  the  fourth  to  the  eighth  year,  2  grains  of  antipyrin  and 
5  grains  of  bromid  of  soda  at  two-hour  intervals — 6  doses  in  twenty- 
four  hours. 

Quinin  has  been  used  in  a  large  number  of  cases  in  both  private  and 
outpatient  work.  I  find  that  great  benefit  can  be  derived  from  its  use 
if  a  large  amount  can  be  given.  Its  administration,  however,  is  at- 
tended with  difficulties.  Twelve  to  twenty  grains  in  twenty-four 
hours  are  required  for  pronounced  results  in  children  from  two  or  six 
years  of  age,  and  the  administration  of  such  a  large  amount  is  not 
favorably  received  by  many  parents.  Again,  our  inability  to  make  the 
the  drug  palatable  is  a  serious  drawback  for  any  age,  and  almost  ex- 
cludes its  use  in  the  very  young;  furthermore,  in  the  very  young 
and  delicate  quinin  may  derange  the  stomach  and  produce  vomiting. 
The  best  form  of  solution  to  use  is  that  of  bisulphate  in  Yerberzine 
(Lilly).  In  older  children,  when  quinin  can  be  given  in  sufficient 
quantities  in  capsules,  the  decrease  in  the  number  and  severity  of  the 
paroxysms  is  sometimes  surprising. 

Codein  is  to  be  used  in  the  most  severe  forms  of  pertussis,  when 
other  means  fail  to  relieve  the  patient.  One  of  the  most  troublesome 
features  of  the  disease — in  fact,  a  dangerous  feature — is  the  wakeful- 
ness at  night  caused  by  repeated  attacks  of  coughing  and  vomiting. 
When  the  child  cannot  sleep,  I  give  codein  independent  of  the  other 
treatment,  whatever  it  may  be.  For  a  patient  five  years  of  age  3^ 
grain  is  given  at  bedtime  and  repeated  during  the  night  whenever  the 
paroxysms  require.  For  a  child  from  eight  to  twelve  years  of  age, 
%  grain  may  be  given  at  bed-time  and  repeated  twice  if  necessary. 
For  a  child  from  two  to  three  years  of  age,  ^f  o  grain  may  be  given  and 
repeated  not  oftener  than  twice  during  the  night.  The  drug  should 
not  be  continued  longer  than  a  week  or  ten  days.  I  have  never  seen 
unpleasant  effects  follow  its  use. 

Interrupted  Medication. — It  will  be  observed  that  the  drugs  of 
value  in  whooping-cough  are  the  sedatives.  It  is  well  known  that  by 
the  prolonged  use  of  sedatives  their  effect  is  lost.  For  this  reason  I 
have  found  it  wise  to  use  what  may  be  called  "  interrupted  medication." 


MEASLES  619 

For  five  days  the  antipyrin  and  bromid  of  soda  are  given.  Full  doses 
of  quinin  only  are  then  given  for  five  additional  days,  at  the  end  of 
which  time  the  antipyrin  and  bromid  are  resumed.  In  this  way, 
giving  the  drugs  five  days  each,  I  continue  with  advantage  for  a  month 
or  six  weeks.  It  is  rarely  necessary  to  continue  the  treatment  longer 
than  six  weeks — usually  from  three  to  four  weeks  is  sufficient.  Of 
course,  the  child  will  whoop  after  that  time,  but  the  active  stage  of 
vomiting  and  severe  paroxysms  will  be  over.  If  the  vomiting  can  be 
controlled  in  an  attack  of  pertussis,  and  if  the  patient  can  obtain  suffi- 
cient sleep,  much  has  been  accomplished.  I  would  emphasize  here, 
what  has  already  been  suggested:  do  not  begin  the  drug  treament  of 
whooping-cough,  whether  by  the  administration  of  quinin,  antipyrin, 
or  other  remedies,  until  the  spasmodic  stage  is  at  its  height.  If  a  sedative 
is  given  as  soon  as  a  diagnosis  is  made,  by  the  time  the  disease  reaches 
its  height  tolerance  will  have  become  so  established  that  the  drug 
will  have  lost  not  a  little  of  its  sedative  action.  If  medicines  must  be 
given  during  the  earliest  stage,  a  placebo  may  be  used. 

Fresh  air  is  of  immense  value  as  a  means  of  relief  in  whooping- 
cough,  regardless  of  the  method  of  treatment  followed.  We  are  told 
that  the  child  rarely  coughs  when  out-of-doors,  but  commences  as 
soon  as  he  is  brought  into  the  house,  which  is  usually  overheated 
and  badly  ventilated.  In  nearly  all  cases  the  cough  is  worse  at  night. 
This  may  be  explained  in  part  by  the  absence  of  proper  ventilation 
in  the  sleeping  apartment.  A  child  who  for  any  reason  must  remain 
indoors  should  not  be  allowed  to  remain  constantly  in  one  room. 
There  should  be  two  rooms  and  every  window  in  the  one  not  in  use 
should  be  freely  open.  The  living-room  and  sleeping  room  should 
be  kept  at  a  fairly  even  temperature — from  68  to  70°F. 

MEASLES 

By  some  writers  measles  is  credited  with  an  antiquity  as  great  as 
that  of  smallpox,  but  the  fact  that  measles  was  long  confused  with 
other  exanthemata  renders  it  doubtful  whether  descriptions  over  two 
centuries  old  should  be  accepted.  Measles  has  always  been  one  of  the 
most  rapidly  advancing  of  epidemic  diseases.  In  communities  long 
unaffected,  such  as  Iceland  and  the  Fiji  Islands,  it  has  attacked  the 
greatest  numbers  and  developed  the  highest  virulence.  In  the  years 
1834  to  1836,  and  1842  to  1843,  nearly  the  whole  of  Europe  .  was 
invaded. 

Buxton,  whose  elaborate  little  monograph,  published  a  century  and 
a  quarter  ago,  still  affords  much  of  value,  says:  "Those  who  die  of 
measles  generally  receive  their  death  by  a  great  flux  of  serum  to  the 
lungs."  Certain  it  is  that  bronchopneumonia  has  always  given  to 
measles  an  importance  out  of  all  proportion  to  its  immediate  severity. 

Transmission. — Measles  is  the  most  readily  transmitted  of  all  the 
communicable  diseases.  A  very  few  seconds'  exposure  is  all  that  is 
necessary.     Very  few   of  the   human  race  escape.     The   disease  is 


620  THE    PRACTICE    OF    PEDIATRICS 

transmitted  by  direct  infection.  Transmission  through  an  intermedi- 
arj^  is  not  of  frequent  occurrence.     I  have  never  known  a  proved  case. 

Etiology. — The  disease  may  be  transmitted  from  the  beginning  of 
the  earUest  catarrhal  symptoms,  which  become  manifest  two  or  three 
days  before  the  appearance  of  the  rash.  The  most  infective  period  is 
during  the  first  four  or  five  days ;  how  much  longer  it  may  continue  is 
unknown. 

Goldberger  and  Anderson  have  been  able  to  produce  measles  in 
rhesus  monkeys  by  inoculating  them  with  the  blood  of  human  cases  of 
the  disease.  They  proved  that  the  blood  in  measles  is  infected  before 
the  appearance  of  the  rash  and  during  efiloresence  of  the  eruption, 
while  the  infectivity  decreases  twenty-four  hours  after  the  eruption 
has  appeared.  The  buccal  and  nasal  secretions  are  also  infective  at 
the  time  of  the  appearance  of  the  eruption  and  for  forty-eight  hours 
afterward.  The  desquamating  scales,  on  the  other  hand,  were  not 
infective.  The  nature  of  the  virus  has  not  been  proved,  but  it  is 
filterable  through  a  Berkefeld  filter,  resists  drying  for  twenty-four 
hours,  and  becomes  inert  after  fifteen  minutes'  exposure  to  55°C. 

Lucas  and  Prizner  have  confirmed  the  work  of  Anderson  and  Gold- 
berger, and  showed  further  that  the  inoculated  monkeys  develop 
Koplik  spots  just  as  do  human  subjects. 

Age. — No  age  is  exempt.  In  scarlet  fever  and  diphtheria,  nature 
surrounds  the  very  young  with  a  certain  degree  of  immunity.  The 
tenderest  age  is  susceptible  to  measles,  although  it  rarely  occurs  in 
infants  under  six  months  of  age. 

Incubation. — The  period  of  incubation  ranges  from  seven  to  four- 
teen days.  It  is  rare  for  the  disease  to  develop  after  the  tenth 
day  following  exposure.  I,  have  known  a  very  few  cases  to  develop, 
however,  as  late  as  the  fourteenth  day. 

Symptoms. — In  marked  contrast  to  scarlet  fever,  measles  is  fairly 
constant  in  its  manifestations.  Very  severe  cases  and  very  mild  cases 
are  encountered.  Institutional  children  have  measles  much  more 
severely  than  do  private  patients,  and  the  former  cases  are  much  the 
more  fertile  in  complications.  This  is  because  of  the  natural  dis- 
advantages which  an  institution  necessitates,  no  matter  how  well 
it  is  conducted.  The  complications  are  more  frequent  because  of 
the  more  frequent  presence  of  secondary  infection  to  produce  the 
comphcations. 

The  Eyes. — The  first  manifestation  of  the  illness  is  a  coryza  with 
mild  conjunctivitis.  The  eyelids  become  swollen  and  reddened  at  the 
margins.     There  is  photophobia. 

Cough. — A  cough  is  present  from  the  beginning  or  develops  in  a 
short  time.  The  cough  is  hard,  teasing,  and,  early  in  the  attack, 
without  bronchial  secretion.  Occasionally  the  cough  will  be  hoarse 
and  croupy,  but  this  is  of  rare  occurrence. 

Nervous  Manifestations. — Convulsions  occur  very  rarely,  and  when 
present  are  usually  due  to  indigestion.  The  child  is  very  restless 
and  unhappy  until  the  eruption  is  well  developed. 


PLATE  II 


Fig.  1. 


PiQ.  2 


Fig.  3. 


Fig.  4. 


Fig, 


The  Pathognomonic  Sign  of  Measles  (Koplik's  Spots). 
1. — The  discrete  measles  spots  on  the  buccal  mucous  membrane,  showing  the 


isolated  rose-red  spot,  with  the  minute  bluish-white  center,  on  the  normally  colored 
mucous  membrane. 

Fig.  2. — Shows  the  increased  eruption  of  spots  on  the  mucous  membrane  of  the 
cheeks;  patches  of  pale  pink  interspersed  among  rose-red  areas,  the  latter  shomng 
numerous  pale  bluish-white  spots. 

Fig.  3. — The  appearance  of  the  buccal  mucous  membrane  when  the  measles  spots 
coalesce  and  give  a  diffuse  redness,  with  myriads  of  bluish-white  specks.  The  ex- 
anthema is  at  this  time  fully  developed. 

Fig.  4. — Aphthous  stomatitis  sometimes  mistaken  for  measl(>s  spots.  Mucous 
membrane  normal  in  color.  Minute  ijellow  poiiits  are  siu-rounded  by  a  red  area. 
Alwavs  discrete; 

(The  Medical  News,  June  .3,  1S99.) 


MEASLES  621 

The  Rash. — The  characteristic  rash  usually  makes  its  appearance 
about  the  ears  and  over  the  neck  and  upper  portion  of  the  chest. 
From  here  it  spreads  to  the  entire  body,  the  last  portions  involved 
being  the  feet  and  hands.  In  its  disappearance,  the  rash  follows  the 
same  order.  It  consists  of  red  papules  and  macules  of  irregular 
shape  and  of  variable  size.  Early  in  all  cases,  and  throughout  most  mild 
cases,  there  are  areas  of  uninvolved  skin  between  the  erupted  areas. 
In  severe  cases  the  areas  of  eruption  coalesce  so  that  the  face,  trunk, 
and  limbs  or  the  entire  skin  surface  may  present  a  livid,  deeply  con- 
gested appearance.  The  face,  covered  with  the  diffuse  rash,  swollen 
and  edematous,  the  eyes  with  the  swollen  lids  closed  and  secreting,  and 
the  thin,  watery  nasal  discharge  present  a  picture  seen  in  many  cases 
of  measles  and  never  elsewhere. 

The  rash  is  sometimes  quite  irregular  in  the  time  of  its  appearance 
after  the  onset  of  symptoms.  I  have  seen  it  occur  very  early,  coin- 
cident with  the  onset  of  the  catarrhal  symptoms,  and  I  have  seen  it 
delayed  for  a  week.  The  eruption  requires  from  three  to  six  days  to 
complete  development. 

Temperature. — Pronounced  fever  does  not  develop  until  the  appear- 
ance of  the  rash.  Both  the  temperature  and  the  rash  reach  their  great- 
est intensity  at  the  same  time.  Rarely  there  is  a  prodromal  fever  for 
a  few  hours.  This  may  reach  103°  to  104°  F.  This  fever  subsides 
quickly  and  the  indications  are  that  the  exposed  child  will  not  develop 
the  disease.  Within  forty-eight  hours,  however,  or  less,  the  tem- 
perature again  begins  to  rise  with  the  appearance  of  the  rash.  In 
cases  of  this  nature  I  have  had  difficulty  at  the  outset  in  persuading 
parents  of  the  necessity  of  keeping  the  child  in  his  bed,  or  even  in  the 
house,  as  the  illness  is  looked  upon  by  the  family  as  a  cause  of  false 
alarm. 

Diagnosis  and  Differential  Diagnosis. — The  diagnosis  in  most  cases 
of  measles  is  not  difficult.  A  mild  case  may  closely  simulate  one  of  se- 
vere German  measles.  The  presence  of  Koplik  spots  (see  Plate  II)  on 
the  buccal  mucous  membrane,  the  conjunctivitis,  and  cough  are  usually 
sufficient  to  mark  the  case  as  one  of  true  measles. 

There  are  no  other  skin  manifestations  of  disease  that  simulate 
those  of  measles  sufficiently  to  occasion  confusion. 

Complications. — Children  with  measles  almost  always  have  some 
bronchitis.  In  fact,  a  mild  degree  of  bronchitis  occurs  so  regularly 
that  it  may  be  looked  upon  as  part  of  the  disease. 

Bronchopneumonia  is  the  most  frequent  complication,  because  the 
diseased  mucous  membrane  of  the  respiratory  tract  becomes  a  fertile 
field  for  infection  with  pneumococcus  and  other  pathogenic  bac- 
teria. The  mortality  in  institutions  for  children  with  measles  is  al- 
ways large,  because  of  the  complication  of  bronchopneumonia.  In  a 
recent  epidemic  of  measles  thus  complicated,  in  a  New  York  institution 
for  children,  there  was  a  mortality  of  40  per  cent. 

Otitis, — Acute,  simple,  and  suppurative  otitis  is  a  fairly  frequent 
complication.     Its  presence  should  be  suspected  when  the  temperature 


622  THE    PRACTICE    OF    PEDIATRICS 

is  continued  and  does  not  subside  with  the  disappearance  of  the  rash. 
The  absence  of  pain  does  not  mean  that  the  ears  are  normal.  In  the 
majority  of  my  cases  of  suppurative  otitis  in  young  children  pain  has 
been  absent. 

Nephritis  is  a  very  rare  complication.     I  have  seen  but  one  case. 

Adenitis. — Adenitis  is  a  rare  complication. 

Recurrence  or  Second  Attack. — I  have  known  of  one  recurrence 
after  a  two-year  interval  in  a  girl  seventeen  years  of  age.  I  attended 
her  during  both  attacks,  the  last  of  which  was  very  severe,  and  followed 
by  a  moderately  severe  nephritis.  The  family,  most  intelligent  and  reli- 
able people,  insisted  that  the  girl  had  had  measles  at  an  earlier  age,  to- 
gether with  other  members  of  the  household.  If  such  was  the  case^ 
she  had  three  attacks  of  measles. 

A  brother  of  the  patient  was  also  reported  by  the  mother  to  have 
had  two  attacks  of  the  disease. 

Prognosis. — The  prognosis  is  good  in  the  cases  in  which  pneumonia 
does  not  enter.  I  have  never  known  a  fatal  uncomplicated  case  of 
measles. 

Treatment. — General  Management. — The  popular  conception  of  the 
management  of  measles  is  that  the  patient  should  be  warmly  wrapped,, 
given  hot  drinks;  and  kept  in  a  warm  room  with  little  or  no  ventilation. 
An  attack  of  measles  renders  the  child  temporarily  a  very  susceptible 
subject  for  bronchopneumonia.  The  younger  and  more  delicate  the 
child,  the  greater  the  danger.  The  darkened  room,  with  its  closed 
windows  and  dust,  the  extra  wrappings,  with  the  resulting  failure  of 
heat  radiation,  the  reduced  vitality,  and  the  resulting  loss  of  appetite 
do  much  to  prepare  the  way  for  an  infection  of  the  respiratory  tract, 
which  so  often  occasions  pneumonia  and  bronchopneumonia.  If  to  a 
case  of  this  nature  whooping-cough  be  added,  we  have,  with  few  ex- 
ceptions, a  hopeless  condition. 

A  child  ill  with  measles  should  be  comfortably  clad  in  the  usual 
night-clothes  and  kept  in  bed.  No  extra  wraps  are  required,  nor  is  it 
desirable  to  keep  the  room  at  a  higher  temperature  than  is  customary 
— 68°  to  70°F.  is  a  suitable  room  temperature.  There  are  many  grada- 
tions of  light  between  glaring  sunlight  and  utter  darkness.  Both  are 
extreme  and  one  almost  as  undesirable  as  the  other.  It  is  my  custom 
to  advise  that  a  window-shade  of  dark  green  be  lowered  within  one 
foot  of  the  window-sill.  The  hght  brown  or  drab  shade  should  be 
lowered  completely.  If  the  shade  is  white,  or  of  a  very  light  color,  and 
not  supplemented  by  a  curtain  of  dark  material,  it  will  be  necessary  to 
exclude  the  bright  light  by  some  other  means.  If  the  child  is  old  enough 
I  allow  him  to  dictate  the  degree  of  light.  Any  intelligent  child  will 
know  when  the  light  is  painful  to  him. 

Feeding. — The  patient  should  be  put  on  a  greatly  reduced  diet.  For 
the  bottle-fed,  the  milk  mixture  should  be  diluted  at  least  one-half  by 
adding  boiled  water,  and  the  same  quantity  given  as  in  health.  The 
appetite  in  the  early  stage  of  measles  is  practically  absent,  so  that  little 
or  no  food  is  taken.     Patients  may  be  given  water  to  drink  freely  at  a 


MEASLES  623 

temperature  not  lower  than  50°F.  For  "runabout"  children,  eighteen 
months  of  age  and  over,  the  diet  as  suggested  for  the  sick  (see  p.  109) 
should  be  given. 

Bowel  Function. — There  should  be  one  evacuation  of  the  bowels 
daily.  An  enema  should  be  given  when  this  does  not  otherwise  take 
place.     The  urine  should  be  examined  every  second  day. 

The  Eyes. — During  the  waking  hours  the  eyes  should  be  generously 
bathed  every  hour  or  two  with  a  3  per  cent,  solution  of  boric  acid  applied 
with  old  linen  or  cotton,  which  is  afterward  destroyed. 

The  Ears. — Otoscopic  examination  should  be  made  every  second 
day  until  the  case  is  discharged.  In  the  event  of  a  sudden  rise  in 
temperature  during  convalescence,  which  cannot  be  explained  by  the 
condition  of  the  intestine,  lungs,  or  throat,  such  an  examination  should 
be  made  by  an  expert. 

Baths. — The  temperature  of  uncomplicated  measles  is  rarely  high 
enough  to  call  for  special  measures.  If  it  should  have  a  tendency  to 
continue  about  104°F.  for  eight  or  ten  hours  and  the  child  be  uncom- 
fortable and  restless,  a  tepid  sponge-bath  of  ten  or  twenty  minutes 
duration  maybe  given,  and  repeated  at  intervals  of  two  ol"  three  hours. 
Whether  the  fever  demands  bathing  or  not,  the  patient  should  be 
sponged  twice  a  day  with  tepid  water  at  100°F.  After  he  has  been 
dried  an  application  of  cold-cream,  liquid  albolene,  or  olive  oil  should 
be  made  to  the  entire  body.  This  is  to  be  given  for  the  sole  reason  that 
it  relieves  the  itching,  induces  sleep,  reduces  the  temperature,  and 
thus  enables  the  child  to  pass  through  the  disease  with  less  discomfort. 

Delayed  Rash. — Now  and  then  a  case  is  encountered  in  which  the 
rash  is  slow  in  appearing.  The  temperature  is  high — 104°  to  105°F., 
— the  skin  hot  and  dry,  and  the  child  very  uncomfortable,  perhaps  de- 
lirious. For  such  patients  a  hot  bath — 105°F.  to  110°F. — of  from 
three  to  five  minutes'  duration,  often  brings  out  the  rash  and  greatly 
relieves  the  symptoms,  which  may  have  been  of  an  urgent  character. 
In  removing  these  children  from  the  bath  care  must  be  exercised  to 
keep  them  wrapped  for  fifteen  to  twenty  minutes  in  a  blanket  which 
has  previously  been  warmed. 

The  Cough. — The  cough  of  measles  during  the  active  period  of  the 
attack  is  one  of  the  annoying  features  of  the  disease,  and  one  for  which 
some  rehef  must  be  attemped,  particularly  if  the  child  is  kept  awake 
at  night.  The  ordinary  expectorants  alone  are  of  no  service  in  treat- 
ing the  cough  of  measles.  Only  a  sedative  will  give  relief.  To  a  child 
six  months  of  age  from  5  to  8  drops  of  paregoric  may  be  given,  and  re- 
peated if  necessary  after  an  interval  of  two  hours.  The  following  com- 
bination of  paregoric  and  sweet  spirits  of  niter  is  often  of  service: 

I^     Tincturae  opii  camphoratse .• gtt.  x 

Spiritus  setheris  nitrosi gtt.  iij 

M.  Sig. — One  dose;  to  be  repeated  every  two  or  three  hours  (for  a  child 
of  eighteen  months  or  older). 

From  the  first  to  the  second  year,  10  to  15  drops  of  paregoric  or  ^^ 
grain  of  Dover 's  powder  may  be  given  at  two-hour  intervals,  if  required. 


624  THE    PRACTICE    OF    PEDIATRICS 

Usually  but  two  or  three  doses  of  the  sedative  will  be  necessary  during 
the  night.  Should  the  paregoric  or  Dover's  powder  be  objectionable 
because  one  may  dislike  to  give  opium  to  young  children,  from  3  to  4 
grains  of  sodium  bromid  in  2  drams  of  water,  repeated  as  required  every 
hour  or  two,  will  be  of  service  for  a  child  under  two  years  of  age.  From 
the  second  to  the  fifth  year  1  grain  of  Dover's  powder,  or  from  15  to  25 
drops  of  paregoric,  or  J-f  o  to  %  grain  of  codein,  may  be  given  at 
intervals  of  from  two  to  four  hours. 

If  bronchitis  develops  sufficiently  to  require  treatment,  as  it  does 
in  at  least  one-half  the  cases,  the  means  for  the  management  of  bron- 
chitis suggested  on  p.  311  will  be  found  useful.  The  temperature  of  a 
child  ill  with  measles  should  be  taken  three  times  daily,  and  the  lungs 
and  heart  should  be  examined  every  day. 

Vapor. — It  is  my  custom  to  keep  the  air  of  the  sick-room  moistened 
with  vapor  during  the  entire  illness.  Its  benefits  are  twofold:  It 
relieves  the  cough,  as  it  is  more  agreeable  than  dry  air  to  the  congested 
mucous  surface  during  the  early  stage;  and  it  prevents  the  free  circula- 
tion of  dust,  the  danger  of  which  has  already  been  referred  to.  If  the 
room  is  carpeted,  it  should  be  well  sprinkled  with  water  before  sweep- 
ing. If,  fortunately,  the  floor  is  bare,  the  broom  can  be  dispensed  with 
and  a  damp  cloth  used  instead. 

Fresh  Air. — Not  only  should  the  air  of  the  sick-room  be  vapor- 
charged,  but  it  should  be  frequently  changed  through  proper  ventilation. 

Quarantine. — The  length  of  quarantine  is  usually  from  twelve  to  six- 
teen days,  at  least  ten  days  of  which  time  are  spent  in  bed. 

GERMAN  MEASLES  (ROTHELN;  RUBELLA) 

German  measles  is  a  disease  of  the  runabout  and  school-chil^-     It 
rarely  occurs  in  infants.     It  is  one  of  the  mildest  diseases  of  the  trtos^ 
missible  class. 

Etiology. — The  specific  etiologic  agent  of  German  measles  is  quite 
unknown,  but  that  it  is  not  identical  Avith  that  of  either  measles  or 
scarlet  fever  is  evidenced  by  the  fact  that  an  attack  of  rubella  does  not 
protect  against  either  of  these  diseases. 

Transmission  is  by  direct  contact.  I  have  never  had  proof  of  the 
transfer  through  an  intermediary.  I  have  never  known  of  a  second 
attack. 

Incubation. — The  period  of  incubation  is  from  two  to  three  weeks. 

Symptoms. — The  first  symptom  is  usually  the  rash.  The  tem- 
perature rarely  goes  above  101°F.  In  a  very  few  cases  I  have  known 
the  temperature  to  rise  to  102°F.,  and  the  rise  has  occurred  at  the  on- 
set of  the  illness.  The  catarrhal  symptoms  are  negligible.  There  is 
rarely  more  than  a  slight  injection  of  the  conjunctiva. 

The  rash  is  not  only  the  first  manifestation  of  the  disease,  but  it 
remains  the  principal  evidence  of  the  infection.  The  eruption  closely 
resembles  that  of  measles,  and  differentiation  between  the  two  diseases 
from  the  standpoint  of  the  rash  may  be  difficult.  It  usually  appears 
first  about  the  ears  and  neck  and  spreads  rapidly.     The  eruption  at 


DIPHTHERIA  625 

first  is  distinctly  smaller  than  that  of  measles;  it  is  papular  and  varies 
from  a  faint  red  to  a  deep  red  color;  rarely  it  is  distinctly  punctate. 
When  this  is  the  case,  the  erupted  areas  may  coalesce,  producing  a 
diffuse  blush  not  unlike  that  of  scarlet  fever.  The  eruption  is  usually 
very  temporary,  lasting  from  one  to  three  days.  It  disappears  after 
the  order  of  its  appearance,  leaving  the  face  and  the  neck  first.  There 
is  no  resulting  pigmentation  or  discoloration  of  the  skin,  such  as  may 
occur  in  true  measles. 

There  is  no  involvement  of  the  buccal  surfaces. 

Lymphatic  Gland  Enlargement. — Enlargement  of  the  glands  at  the 
angle  of  the  jaw  and  the  post-cervical  glands,  particularly  the  latter, 
occurs  so  consistently  that  this  condition  may  be  put  down  as  one  of 
the  prominent  symptoms  of  the  disease.  The  glandular  involvement, 
however,  is  very  slight,  and  disappears  in  from  two  to  four  days.  The 
glands  in  the  axilla  and  groin  very  rarely  show  involvement. 

Desquamation. — Only  the  severer  cases  are  followed  by  a  slightly 
branny  desquamation. 

Diagnosis  and  Differential  Diagnosis.— The  disease  may  be  confused 
with  measles,  scarlet  fever,  and  the  indigestion  and  drug  erythemata. 
The  mildness  of  the  symptoms  is  a  strong  point  in  favor  of  German 
measles.  Exceptionally,  a  severe  case  may  be  difficult  to  differentiate 
from  true  measles.  In  such  an  instance  the  absence  of  eruption  on  the 
buccal  mucous  membrane  (Koplik  spots)  is  a  valuable  aid.  Further, 
the  lymph-gland  enlargement  does  not  occur  in  measles. 

Scarlet  Fever. — The  characteristic  angina,  which  is  a  fairly  constant 
symptom  in  scarlet  fever,  is  never  present  in  measles.  There  is  no  post- 
cervical  gland  enlargement  early  in  scarlet  fever;  and  while  the  rash 
of  German  measles  may  resemble  that  of  scarlet  fever,  the  former 
exanthem  is  coarser  in  appearance,  the  punctate  dots  are  larger,  and  the 
rash  presents  a  blotched  appearance,  in  contradistinction  to  the  general 
diffuse  intense  blush  of  scarlet  fever.  In  scarlet  fever,  furthermore,  the 
desquamation  is  characteristic.  In  erythema  due  to  drugs  there  is  no 
manifestation  of  illness  of  any  nature.  A  rash  due  to  indigestion  is 
very  transient  and  is  apt  to  be  urticarial  in  type. 

Complications. — I  have  never  known  a  complication  to  develop 
with  this  disease. 

Prognosis. — I  have  never  known  a  fatal  case. 

Treatment. — Rest  in  bed  for  about  two  days,  confinement  to  the 
house  for  a  slightly  longer  period,  reduced  diet,  and  the  promotion  of 
free  bowel  action  are  usually  all  that  are  needed.  Recovery  is  ordi- 
narily complete  in  six  to  eight  days  from  the  beginning  of  the  attack. 

Isolation  is  not  a  necessity  unless  there  are  very  young  or  delicate 
children  in  the  family. 

DIPHTHERIA 

Diphtheria  has  been  known  by  its  present  name  for  less  than  a 
century,  although  the  terms  "ulcus  Syracum "  and  " ulcus  Egyptacum," 
together  with  references  to  certain  anginas  with  very  pecuHar  expec- 
40 


626  THE    PRACTICE    OF    PEDIATRICS 

toration,  indicate  that  the  disease  was  prevalent  as  far  back  as  the  time 
of  Hippocrates.  As  early  as  100  B.  C.  Asclepiades,  of  Bithynia,  quoted 
by  Galen  and  Aretseus,  is  said  to  have  known  diphtheria  and  practised 
laryngotomy.  Aretseus  gave  the  first  important  description  of 
"angina  gangrenosa/'  and  Galen,  in  the  second  century,  described  the 
membranous  expectoration. 

Not,  however,  until  the  early  part  of  the  eighteenth  century  did 
study  of  the  disease  become  productive.  In  1719  Wolfgang  Wedel,  of 
Jena,  issued  a  document  on  the  value  of  isolation.  A  little  later  an 
epidemic  near  Boston,  and  in  1745  another  in  Paris,  resulted  in  the 
description  of  cutaneous  diphtheria  and  of  paralysis  of  the  palate  and 
eye  muscles.  Home  accurately  described  the  membranes  in  1765  and 
invented  the  term  "croup,"  to  differentiate  the  condition  under  dis- 
cussion from  the  " angina  maligna"  or  "gangrenosa"  of  ancient  writers. 
Not  until  the  publication  in  1826  of  Bretonneau's  famous  treatise  on 
the  epidemics  at  Tours  was  the  pathology  of  the  disease  accurately 
defined.  Bretonneau  combined  all  the  inflammations  previously  called 
angina  gangrenosa,  ulcers,  and  croup  under  the  term,  diphtheria 
(At00i7pa,  a  membrane)  and  asserted  his  belief  that  direct  inoculation 
and  contact  were  the  only  modes  of  transmission. 

The  later  history  of  diphtheria  contains  its  two  most  important 
epochs:  the  discovery  by  Klebs  of  the  bacillus,  in  1883,  with  its  isolation 
and  cultivation  by  Loffler  in  1884;  and  the  introduction  of  antitoxin 
into  general  use  as  a  result  of  long  experimentation  (by  Behring,  Roux, 
Martin,  Chaillon,  and  Yersin)  with  the  serum  of  actively  immunized 
animals.  Since  the  report  of  Roux  in  1894  that  m  certain  hospitals 
antitoxin  had  reduced  the  mortality  from  58  per  cent,  to  2'0-pCT  cent., 
the  wider  and  more  intelligent  use  of  this  specific  has  revolutionized^4rer 
disease. 

Age  of  Patients. — Diphtheria  is  of  rare  occurrence  before  the  first 
year,  although  no  age  is  exempt.  My  youngest  patient  was  five 
months  of  age.  A  case  in  the  practice  of  a  colleague  occurred  at  the 
sixth  week.  The  most  susceptible  age  is  between  the  second  and  the 
tenth  year. 

Predisposition. — Vigor  of  constitution  appears  to  exert  no  influence 
on  susceptibility  to  the  disease.  The  strong  and  the  delicate  are  alike 
subject  to  the  infection. 

Diseased  Throats. — The  presence  of  diseased  tonsils  and  adenoids 
appears  to  be  a  decided  predisposing  factor.  Throats  so  involved 
possess  a  poor  resistance  to  the  infection.  It  is  my  observation  that  a 
normal  throat  is  the  best  prophylactic  agent,  which  means  that  chil- 
dren whose  diseased  tonsils  and  adenoids  have  been  removed  have  the 
best  chance  to  escape  after  an  exposure. 

Transmission. — Diphtheria  is  contagious  and  infectious ;  transmis- 
sible through  contact — contagious;  and  through  an  intermediary — in- 
fectious. Transmission  from  the  diseased  to  the  well  is  usually  through 
personal  association.  That  the  disease  may  be  transmitted  through  an 
intermediary  person,  book,  or  article  of  clothing,  is  not  to  be  questioned. 


DIPHTHERIA 


627 


Nevertheless,  I  am  confident  that  sources  of  exposure  are  much  less 
frequent  than  is  generally  accepted.  The  sources  of  many  obscure  in- 
fections are  the  mild  ambulatory  cases.  Diphtheria  may  be  so  mild  in 
an  individual  that  its  presence  is  not  suspected,  and  to  such  cases  is  due 
in  many  instances  the  spread  of  the  disease. 

Diphtheria  Carriers. — In  several  instances  I  have  demonstrated  the 
presence  of  the  diphtheria  bacillus  in  the  nasal  secretions  of  healthy 
children.  In  a  series  of  observations  in  pubUc  school  children  in  Balti- 
more Styles  found  diphtheria  bacillus  in  5  per  cent,  of  cases. 

Bacteriology. — The  morphology  of  the  Klebs-Loffler  bacillus  varies 
greatly,  but  it  has  a  characteristic  irregularity  of  staining  and 
regularity  of  grouping  which  are  aids  to  diagnosis.  Its  demonstration 
in  smears  or  cultures  from  the  site  of  the  lesion  is  a  necessity  for  the 
diagnosis  of  diphtheria.  With  the  weakly  alkaline  methylene-blue 
stain  recommended  by  Loffler  the  bacilli  appear  striped,  unevenly 
beaded,  granular,  or  clubbed ;  they  are  arranged  in  groups  of  four  or  six 
elements,  lying  parallel  or  at  sharp  angles. 

The  most  frequent  localization  of  Bacillus  diphtherise  in  the  human 
body  is  on  the  mucosa  of  the  throat,  larynx,  and  nose.  It  may  travel 
down  into  the  lung,  causing  bronchopneumonia,  or  into  the  stomach, 
causing  pseudomembranous  gastritis.  The  bacilli  have  been  found  in 
pus  from  the  middle  ear,  and  the  pseudomembranous  lesions  on  the 
skin  and  vulva.  As  a  rule,  Bacillus  diphtherise  remains  localized  at 
the  site  of  the  lesion  it  has  produced,  and  only  in  very  rare  instances 
does  it  invade  the  blood — probably  as  a  terminal  condition.  The 
toxin  formed  by  the  bacillus  is  responsible  for  the  general  symptoms. 

The  bacillus  may  persist  in  the  throat  for  weeks  after  an  attack  of 
diphtheria,  however  mild  such  an  attack  may  have  been.  These  bacil- 
lus carriers  become  a  menace  to  other  persons,  since  a  mild  attack  of 
diphtheria  in  one  individual  may  yet  produce  a  severe  case  in  another 
person. 

The  Schick  Test. — In  the  Schick  test  a  minute  quantity  of  diph- 
theria toxin  is  introduced  intra-dermally.  The  effects  indicated  by  a 
local  reaction  determine  the  susceptibility  of  the  individual  to 
diphtheria. 

Susceptibility  to  Diphtheria. — As  mentioned  elsewhere  very  young 
infants  have  been  looked  upon  as  possessing  a  natural  immunity  to 
diphtheria.  Among  several  hundred  cases  I  have  seen  but  two  under 
six  months  of  age. 

Interesting  observations  as  to  the  susceptibility  of  children  at 
various  ages  have  been  published  by  Schick,  as  follows: 


Age 


Total 


Schick's 


Positive 
Schick's 


Per  cent. 
positive 


New-born .  .  . 

1st  year 

2  to  5  years. . 
5  to  15  years 
Totals 


291 

42 

150 

264 

747 


275 
24 
55 

133 

487 


16 

18 

95 

131 

260 


7 

43 

63 

50 

34-9 


628  THE    PRACTICE    OF    PEDIATRICS 

It  will  be  observed  that  in  the  newly  born  but  7  per  cent,  were 
susceptible  to  diphtheria.  Among  747  children  under  fifteen  years 
but  34.9  per  cent,  were  susceptible  to  the  disease.  It  has  also  been 
proven  that  an  attack  of  diphtheria  not  only  causes  no  immunity  but 
renders  the  individual  more  readily  susceptible  to  future  attacks. 

It  has  also  been  demonstrated  that  susceptibility  runs  in  families. 
When  one  child  in  a  family  is  positive  others  are  apt  to  be  positive,  and 
the  same  holds  with  negative  reactions. 

Technic. — Schick  published  an  elaborate  technic  which  was  not 
practicable  for  ordinary  purposes.  Park  and  Zingher  have  simplified 
the  technic  and  I  am  indebted  to  them  for  the  instructions  as  to  its 
apphcation. 

The  toxin  is  supphed  in  capillary  tubes.  The  contents  of  a  tube  is 
mixed  with  10  c.c.  of  sterile  salt  solution  and  0.2  c.c.  of  the  solution  is 
injected  intradermally  with  a  fine  hypodermic  needle. 

There  may  be  three  results  following  intra-cutaneous  injection  of 
diphtheria  toxin : 

Negative. — Where  no  local  reaction  at  all  occurs  about  the  injec- 
tion point. 

Pseudo-positive  (Plate  IV)  (meaning  not  positive  at  all). — Where  a 
red  area,  probably  anaphylactic  in  character,  appears  within  the  first 
twelve  to  twenty-four  hours,  but  disappears  in  thirty-six  to  seventy- 
two,  with  little  or  no  pigmentation. 

Positive  (Plate  III). — Where  in  thirty-six  to  forty-eight  hours,  a  red, 
generally  clearly  outlined  area  about  one-half  to^^^?m.--^^ears  about 
the  injection  point,  which  lasts,  becoming  a  brick  red  in  twoTtHree  or 
four  days,  the  skin  then  wrinkling  and  scahng,  after  which  the  dis- 
coloration gradually  disappears  taking  three  to  six  weeks  to  entirely 
disappear. 

Negative  signifies  immunity.  There  is  sufficient  antitoxin  in  the 
system  to  neutralize  the  poison  introduced. 

Pseudo-positive  also  signifies  immunity. 

Positive  signifies  no  immunity.  There  is  not  enough  antitoxin  in  the 
system  to  neutralize  the  poison  introduced.  The  individual  reacting 
positive  is  susceptible  to  diphtheria. 

The  Schick  test  is  particularly  useful  in  institutions  where  it  is  desir- 
able to  know  the  susceptibiHty  of  the  patients  relative  to  the  use  of 
immunizing  doses  of  antitoxin.  The  possibihties  of  the  pseudo-posi- 
tive reaction  which  might  necessitate  a  delay  in  the  true  reading  of  the 
reaction  have  induced  investigators  to  eliminate  it  if  possible.  KopHk 
and  Unger*  have  devised  a  simple  method  which  they  claim  eliminates 
the  pseudo-positive  reaction  in  75  per  cent,  of  the  cases.  Their  technic 
is  as  follows:  "After  an  area  of  skin  on  the  forearm  has  been  cleansed 
with  alcohol,  the  latter  is  encircled  with  the  thumb  and  index-finger, 
and  the  skin  held  tense  between  them.  The  needle  is  dipped  into  the 
bottle  of  pure  undiluted  diphtheria  toxin  and  then  immediately  inserted 
intradermally.  It  is  important  that  the  needle  be  inserted  intrader- 
*  Journal  A.  M.  A.,  vol.  Ixvi,  No.  xvi. 


PLATE   111 


Shows  four  typical  positive  Schick  reactions  of  varying  degrees  of  intensity 
forty-eight  hours  after  test;  (a)  is  a  strongly  positive  reaction,  with  vesiculation 
of  the  surface  layers  of  the  epithelium,  which  is  seen  occasionally  in  individuals 
who  have  practically  no  antitoxin;  (b)  and  (c)  are  positive  reactions;  (d)  a  mod- 
erately positive  reaction. 


Shows  a  fading  positive  Schick  reaction  one  to  four  weeks  after  test  in  various 
stages  of  scaling  and  pigmentation;  (a)  shows  redness,  scaling  and  beginning 
pigmentation  after  one  week;  (b)  and  (c)  pigmentation  after  two  and  three 
weeks;  (d)  faint  pigmentation  after  four  weeks. 

(ZiNGHER,  American  Journal  of  Diseases  of  Children,  A])ril,  191(1.) 


PLATE    IV 


Shows   two    pseudoreactions    forty-eight    hours    after    test,    and    a   combined 
reaction;    (a)  mild;    (b)  marked;    (c)  a   combined   positive   and    pscudoreaction. 

(ZiNGHER,  American  Journal  of  Diseases  of  Children,  April,  1910.) 


DIPHTHERIA  629 

mally  and  not  subcutaneously.  The  needle  is  an  ordinary  hypodermic 
bent  at  a  distance  of  one-quarter  inch  from  its  point  so  as  to  make  an 
angle  of  about  170  degrees.  The  angle  aids  in  inserting  the  needle  in- 
tradermally.  From  the  place  of  bending  to  the  distal  end  it  is 
shielded  so  that  only  the  unshielded  one-quarter  inch  can  be  inserted  into 
the  skin.  The  needle  is  so  constructed  that  when  it  is  inserted  its  full 
length  the  amount  of  toxin  carried  in  is  approximately  one-fiftieth  of 
the  minimal  lethal  dose.  We  have  had  the  needle  weighed  before  and 
after  dipping  it  into  the  toxin  and  the  difference  was  found  to  be 
0.0001  gm.,  which  was  the  ultimate  possibility  of  weighing  of  the  scales 
used. 

There  can  be  nothing  simpler  than  this  technic.  It  is  practically 
painless.  It  obviates  diluting  the  toxin,  thereby  eliminating  the 
paraphernalia  needed  for  this  purpose.  The  pure  toxin  kept  on  ice 
retains  its  potency  for  one  year.  The  diluted  toxin  used  in  the  Schick 
technic  deteriorates  in  twenty-four  hours.  Another  very  important 
advantage  is  the  reduction  of  pseudo-reactions  to  a  minimum. 

The  authors  believe  that  the  pseudo-positive  reaction  is  due  to 
trauma,  due  to  injecting  intradermally  2  c.c.  of  the  diluted  toxin,  and 
that  it  is  not  the  result  of  anaphylaxis. 

Zingher*  states  that  three  prerequisites  are  necessary  for  the  test: 
(a)  a  reliable  toxin,  (b)  a  proper  technic,  and  (c)  a  correct  interpretation 
of  the  reaction.  Care  in  getting  and  keeping  the  toxin  will  answer  the 
first.  A  good  syringe  (preferably  a  1  c.c),  and  a  fine,  sharp  but  short- 
beveled  platinum-iridium  needle  are  needed  for  the  second.  The  ability 
to  carry  out  the  test  properly  is  easily  acquired.  One  point  that 
may  serve  in  guiding  one  in  the  injection  of  the  diluted  toxin  might  be 
emphasized.  If  the  needle  has  been  inserted  in  the  proper  layer  of  the 
epidermis,  then  the  oval  opening  of  the  needle  will  be  visible  through 
the  superficial  layers  of  cells.  A  definite  wheal-like  elevation,  with  the 
distinct  markings  of  the  openings  of  sweat-glands,  shows  that  the  in- 
jection has  been  made  properly,  and  that  the  fluid  is  confined  to  a  small 
area  of  the  epidermis.  Here  it  will  exert  its  irritant  action  if  the 
individual  tested  is  not  immune  to  diphtheria. 

Conclusions. — 1.  The  great  practical  value  connected  with  the 
Schick  test  makes  it  desirable  that  the  results  obtained  with  it  should 
be  reliable. 

2.  The  accuracy  of  the  results  will  depend  not  only  on  the  toxin, 
but  also  on  the  care  with  which  the  test  is  made,  and  on  the  interpreta- 
tion of  the  reaction. 

3.  The  undiluted  toxin  is  available  in  bulk  or  in  capillary  tubes.  It 
should  be  well  ripened  and  always  kept  cold  and  in  a  dark  place. 

4.  The  positive  reaction  should  be  considered  as  indicating  a  lack  of 
immunity,  unless  the  pseudoreaction  can  be  ehminated  by  a  control 
test.     The  negative  reaction  is  a  definite  sign  of  innnunity. 

5.  It  is  important  to  remember  that,  in  using  diphtheria  toxin  in  the 
Schick  test,  we  are  dealing  with  an  accurate  quantitative  reaction,  and 

*Amer.  Journal  Diseases  of  Children. 


630  THE    PRACTICE    OF    PEDIATRICS 

handling  carefully  measured  amounts  of  an  active  agent,  that  has  a 
tendency  to  deteriorate,  even  in  bulk,  if  it  is  not  properly  protected 
from  light  and  exposure,  and  kept  in  a  very  cold  place. 

6.  The  results  with  the  test  obtained  in  2700  normal  children,  show 
that  from  17  to  32  per  cent,  between  the  ages  of  2  and  16  years  give  a 
positive  reaction  and  are  probably  susceptible  to  diphtheria. 

Pathology. — Following  an  invasion  of  the  mucous  membrane  by  the 
specific  bacillus,  a  pseudomembrane  is  thrown  out  which  is  firmly  ad- 
herent to  the  underlying  mucous  membrane.  The  false  membrane 
may  be  thin  and  grayish  in  color,  or  thick  and  yellow. 

It  is  the  result  of  exudation  into  the  mucosa,  ulceration,  and  ne- 
crosis. The  mass  thus  formed  is  composed  chiefly  of  fibrin,  in  the 
meshes  of  which  are  entangled  polynuclear  leukocytes,  desquamated 
epithelium,  and  bacteria.  The  fibrin  may  be  deposited  in  fairly 
definite  layers.  Ulceration  and  small  hemorrhages  occur  in  the  sub- 
jacent tissue,  which  is  very  edematous,  and  detachment  of  the  mem- 
brane may  leave  a  raw,  bleeding  surface.  When  the  separation  occurs 
naturally,  the  loosening  process  is  one  of  autolysis,  and  large  defects 
in  the  tissue  are  healed  by  granulation.  New  epithelium  is  generally 
flat,  and  cicatricial  contractures  are  common.  The  Klebs-Loffler  bacilli 
present  in  the  exudate  during  the  acute  stage  are  usually  associated 
with  other  organisms,  such  as  streptococci  and  staphylococci,  which 
determine  to  some  degree  the  appearance  of  the  membrane. 

Any  of  the  mucous  surfaces  may  be  involved.  Under  my  own  obser- 
vation the  process  has  involved  the  nasal  cavities,  the  lips,  the  mouth, 
the  conjunctiva,  tonsils,  pharynx,  trachea,  and  bronchi,  and  in  one 
case  the  esophagus.  The  involvement  of  the  trachea,  bronchi,  and 
esophagus  was  proved  at  autopsy.  The  rectum  and  vagina  have  been 
the  seat  of  the  disease. 

Incubation. — The  period  of  incubation  is  variable.  It  may  be  but 
a  day  or  two,  or  it  may  be  several  weeks.  According  to  estimate,  1  per 
cent,  of  school-children  carry  the  bacilli  in  their  throats  in  a  viable  form, 
and  yet  by  no  means  1  per  cent,  of  the  children  develop  the  disease. 

Symptoms. — One  of  the  most  important  features  of  diphtheria,  in 
the  great  majority  of  cases,  is  the  slow  and  gradual  onset.  At  first  the 
child  may  complain  of  being  tired  or  sleepy  and  of  loss  of  appetite. 
Symptoms  referable  to  the  throat  may  appear,  but  pain  is  not  neces- 
sarily present.  The  breath  becomes  offensive.  The  physician  is  sent 
for  on  the  first,  second,  third,  or  some  later  day,  depending  upon  the 
intelligence  of  the  parents  or  nurse  or  upon  their  confidence  in  them- 
selves to  care  for  what,  at  the  time,  appears  to  be  a  simple  condition. 
The  child,  not  willing  to  go  to  bed,  is  looked  upon  by  the  uneducated 
eye  as  being  not  at  all  sick.  By  the  time  the  case  is  seen  by  a  physician 
much  valuable  tima  may  have  been  lost.  The  earlier  antitoxin  is  used, 
the  more  certain  the  recovery.  A  delay  of  forty-eight  or  even  twenty- 
four  hours  may  mean  a  fatal  issue.  Not  every  case  has  so  gradual  an 
onset. 


DIPHTHERIA    .  631 

Illustrative  Cases. — In  the  pre-antitoxin  period,  late  in  the  eighties,  an  asylum 
patient  died  eighteen  hours  after  the  appearance  of  the  first  symptom. 

In  March,  1910,  a  father  came  to  my  office  leading  by  the  hand  two  children, 
aged  three  and  six  years.  Both  had  been  ill  about  three  days  with  fever  and  some 
difficulty  in  swallowing.  They  were  supposed  to  have  tonsillitis.  The  children 
had  not  seemed  at  all  ill  to  the  father.  A  glance  showed  that  they  were  ill.  On 
further  examination  both  throats  were  found  filled  with  membrane.  They  were 
at'once  sent  to  the  Willard  Parker  Hospital  and  given  large  doses  of  antitoxin.  One 
child  died  in  twelve  hours  and  the  other  in  twenty-eight  hours. 

Localization  of  the  Membrane. — The  usual  site  of  the  membrane  is 
on  the  tonsils  and  the  pillars.  The  pharynx  is  more  rarely  involved, 
and  when  involved,  has  usually  become  affected  through  extension  of 
the  primary  lesion. 

Teni'perature. — The  temperature,  unfortunately,  is  rarely  high  early 
in  the  case.  It  seldom  rises  above  102°F.  The  lower  temperature  and 
gradual  onset  are  accountable  for  many  deaths,  the  physician  being 
called  late  in  the  disease. 

The  Lymph  Glands. — Swelling  of  the  lymphatic  glands  at  the  angle 
of  the  jaw  is  an  early  symptom  in  about  30  per  cent,  of  the  cases. 

Diagnosis. — Visible  membrane  should  always  be  looked  upon  as 
diphtheric,  and  treated  accordingly  with  antitoxin.  I  have  looked  into 
thousands  of  throats,  and  feel  sure  that  the  man  is  yet  to  be  born  who 
can  say,  after  inspection  alone,  that  a  given  membrane  is  not  due  to  the 
Klebs-LofHer  bacillus.  There  is  no  invariable  manifestation,  no  reliable 
characterization,  of  pseudomembrane  due  to  the  Klebs-Loffler  bacillus. 

Antitoxin  should  be  given  in  any  suspected  case,  and  then  a  culture 
should  be  taken.  Following  out  this  practice,  I  have  given  antitoxin 
to  children  who  did  not  have  diphtheria,  as  proved  by  repeated  cultures. 
Never  have  I  regretted  this  practice. 

Differential  Diagnosis. — Both  the  streptococcus  and  staphylococcus 
will  produce  a  membrane  identical  with  those  produced  by  the  Klebs- 
LofHer  bacillus,  and  the  disease  may  be  differentiated  only  through  cul- 
tural examination. 

Tonsillitis. — In  tonsillitis  the  temperature  is  high — 103°  to  105°F. 
The  child  is  usually  much  prostrated,  and  appears  very  ill.  The 
physician  accordingly  is  called  much  earher  to  the  patient  ill  with  ton- 
sillitis than  to  the  one  ill  with  diphtheria. 

In  tonsillitis  the  tonsils  are  more  apt  to  be  swollen  and  enlarged,  the 
exudation  appearing  in  the  form  of  white  dots  which  stud  the  surface. 
Care  must  be  exercised,  however,  in  cases  which  appear  to  be  those  of 
frank  tonsillitis.  The  points  of  exudation  may  coalesce  and  in  a  day  or 
two  may  produce  a  distinct  membrane  firmly  organized.  It  is  my  cus- 
tom to  m^ake  a  culture  in  every  case  showing  visible  exudation,  whether 
this  is  on  the  tonsils  or  elsewhere. 

Illustrative  Case. — A  mother  developed  fever  and  sore  throat.  The  left  tonsil 
was  clear.  On  the  right  tonsil  there  were  three  or  four  j^ellowish-white  points  of 
exudation.  The  condition  was  pronounced  tonsillitis  by  the  physician  in  attend- 
ance, and  she  was  not  visited  further.  In  four  days  the  doctor  was  again  sent  for, 
and  found  she  had  diphtheria  with  extensive  membrane  on  both  tonsils.  The 
mother  passed  through  a  desperate  illness  and  recovered  completely  in  six  months. 
In  addition  to  a  myocarditis  she  developed  diphtheric  paralysis  of  both  lower  ex- 
tremities.    Two  of  her  three  boys  who  were  my  own  patients  developed    the 


632  THE    PRACTICE    OF    PEDIATRICS 

disease  and  recovered  without  inconvenience  because  of  the  early  and  free  use  of 
antitoxin. 

I  could  recite  many  other  instances  of  the  atypical  onset  of  diph- 
theria. I  have  learned  never  to  look  lightly  upon  a  throat  showing 
exudation  on  its  mucous  membrane. 

Prognosis. — A  favorable  prognosis  in  a  given  case  depends  largely 
upon  two  factors:  An  early  diagnosis  and  a  knowledge  of  the  use  of 
antitoxin.  The  natural  resistance  of  the  patient  is  an  important  fea- 
ture, and  particularly  important  is  the  condition  of  the  throat,  whether 
normal  and  resistant,  or  filled  with  diseased  tissue,  supplying  a  favor- 
able culture  field  for  the  invading  bacilli. 

Complications. — The  complications,  in  their  order  of  frequency,  are 
bronchopneumonia,  nephritis,  endocarditis,  otitis,  adenitis,  and  diph- 
theric paralysis. 

Treatment.^ — Owing  to  our  knowledge  of  the  etiology  of  diphtheria, 
and  as  a  result  of  the  advent  of  the  specific  remedy,  antitoxin,  the  dis- 
ease has  lost  much  of  its  former  terror.  Diphtheria  is  still,  however, 
an  important  contributor  to  the  death-rate  of  all  large  cities.  This  is 
due,  first,  to  parents  who  fail  to  appreciate  the  possible  dangers  that 
may  arise  from  a  sore  throat  and  who  neglect  to  call  a  physician  early 
in  the  illness,  and,  secondly,  to  physicians  who  do  not  believe  in  diph- 
theria antitoxin,  who  timidly  use  it  in  small  doses  late  in  the  disease,  or 
who  wait  for  positive  clinical  signs  or  a  report  of  a  culture  before  using 
the  remedy.  Equally  as  necessary  as  the  realization  of  the  value  of 
antitoxin  is  the  knowledge  of  how  and  when  to  use  it  and  when  to  re- 
peat its  use.  In  many  cases,  at  the  beginning  of  the  disease,  when  the 
tonsils  alone  are  involved,  it  is  impossible,  without  the  aid  of  the  labora- 
tory, to  differentiate  diphtheria  from  tonsillitis.  I  have  seen  case  after 
case  in  the  pre-antitoxin  period,  in  which  two  or  three  days  were  re- 
quired to  make  a  positive  clinical  diagnosis.  In  towns  in  which  a 
bacteriologic  examination  is  possible  it  is  in  some  instances  safe  to  wait 
for  a  report  from  such  an  examination.  When  one  is  in  doubt,  a  safer 
rule  to  follow  in  those  cases  in  which  there  is  pseudomembrane  on  the 
tonsils  is  to  give  antitoxin  at  once.  If  the  case  proves  to  be  one  of 
simple  tonsillitis,  no  harm  will  follow.  I  have  repeatedly  given  full 
doses  of  antitoxin  to  patients  in  whom  we  afterward  learned  there  was 
no  diptheria,  without  any  unfavorable  results. 

Illustrative  Case. — During  the  winter  of  1906-07,  I  was  called  to  see  a  little  girl 
six  years  old  with  a  gray,  membranous  patch  on  the  left  tonsil,  of  the  size  of  the 
thumb-nail.  There  was  a  temperature  of  101°F.  The  child  complained  of  feeling 
tired,  seemed  generally  wretched,  and  had  considerable  difficulty  in  swallowing.  I 
immediately  gave  3000  units  of  antitoxin  and  sent  to  a  private  laboratory  a  culture 
from  the  throat.  Next  morning  the  report  reached  me  that  the  Klebs-L6fl3er 
bacillus  was  absent.  On  visiting  the  patient  at  this  time  I  found  that  the  mem- 
brane had  extended  and  now  covered  the  right  tonsil.  I  repeated  the  antitoxin, 
giving  .3000  units,  and  took  another  culture.  This  was  sent  to  another  private 
laboratory.  Again  the  report  was  negative  for  the  Klebs-Loffler  bacillus,  but  the 
culture  showed  a  pure  growth  of  the  streptococcus.  The  following  morning  the 
throat  began  to  clear,  and  in  two  days  was  normal.  Clinically  this  case  was  one  of 
diphtheria.  There  was  no  scarlatina,  but  there  was  some  swelling  of  the  glands  at 
the  angle  of  the  jaw.  Aside  from  the  improvement,  the  child  showed  no  symptoms 
whatever  to  indicate  that  antitoxin  had  been  given. 


DIPHTHERIA  633 

Necessity  for  Promptness  in  the  Use  of  Antitoxin. — When  there  is 
diphtheria  and  we  wait  for  positive  dinical  signs  or  for  the  report  of  a 
culture,  if  only  for  ten  or  twelve  hours,  we  lose  most  valuable  time. 
Such  a  delay  may  be  responsible  for  a  fatal  termination.  If  there  is  one 
thing,  in  addition  to  its  great  usefulness,  that  we  have  learned  by  the 
administration  of  antitoxin,  it  is  the  necessity  of  giving  the  agent  at  the 
earliest  possible  moment  in  the  disease  and  of  giving  it  in  full  doses. 
When  in  doubt,  give  antitoxin.  The  age  of  the  child  determines  in  no 
way  the  amount  to  be  given  at  one  time. 

Dosage. — Five  thousand  units  should  be  given  at  the  first  injection. 
When  there  is  membrane  on  the  uvula,  the  pillars  of  the  fauces,  the 
posterior  pharyngeal  wall,  or  in  the  nose,  we  should  never  await  the 
report  of  a  culture,  but  give  a  full  dose  of  antitoxin  at  once.  This 
should  be  repeated  eight  to  twelve  hours  later  if  there  is  an  extension 
of  the  membrane  or  if  there  is  no  change  in  its  appearance.  If  the 
throat  shows  a  tendency  toward  improvement,  if  there  is  a  curling  up 
and  loosening  of  the  edges  of  the  membrane,  or  if  it  has  taken  on  the 
granular  appearance  peculiar  to  diphtheric  membrane  after  the  use  of 


Fig.  85. — "Record"  antitoxin  syringe. 

antitoxin,  we  may  safely  wait  twelve  hours  longer — twenty-four  hours 
in  all — before  deciding  whether  a  repetition  of  the  original  dose  or  the 
administration  of  a  smaller  one  is  required.  In  the  nasal  cases,  a  di- 
minution in  discharge,  a  lessening  of  the  breath  fetor,  a  reduction  in  the 
glandular  swelling,  and  a  fall  in  the  temperature — all  are  indications 
of  improvement,  but  the  physician  should  not  rest  unless  the  constitu- 
tional improvement  and  the  clearing-up  process  are  rapid  and  complete. 
When  the  case  shows  no  sign  of  improvement,  more  antitoxin  should 
be  given. 

A  child  iU  with  diphtheria  must  be  looked  upon  as  poisoned.  Anti- 
toxin is  the  antidote,  and  every  case  must  receive  enough  of  the  antidote 
to  neutralize  the  poison.  Whether  enough  antidote  will  be  supplied 
depends  upon  the  duration  of  the  infection  when  seen  by  the  physician, 
and  upon  his  ability  to  apply  the  remedy.  If  the  case  is  seen  on  the 
third  day  or  after  10,000  units  should  be  the  initial  dose  and  may  be 
repeated  as  suggested  above. 

Means  of  Injection. — There  are  several  antitoxin  syringes  on  the 
market,  any  one  of  which  may  be  used  if  it  will  admit  of  repeated  boil- 
ing, for  in  every  instance  the  syiinge  should  be  boiled  before  using. 
The  ''Record"*  antitoxin  syringe  (  Fig.  85)  satisfactorily  fulfils  these 
requirements.     Some  of  the  private  producers  of  antitoxin  furnish  it 

*  The  "Record"  antitoxin  syringe  may  be  obtained  from  James  C.  Dougherty, 
409  West  Fifty-ninth  Street,  New  York. 


634  THE    PRACTICE    OF    PEDIATRICS 

in  a  glass  bulb  with  an  appliance  for  subcutaneous  injection.  The 
advantages  possessed  by  this  combination  are  its  convenience  and  its 
safety,  for  as  the  instrument  has  to  be  used  but  once,  the  danger  of 
infection  by  means  of  a  syringe  which  is  used  repeatedly  is  thus  avoided. 

Site  of  Injection. — The  skin  over  the  abdomen  between  the  umbilicus 
and  the  anterior  spine  of  the  ilium  is  doubtless  the  most  convenient 
site  for  the  injection.  The  skin  is  very  loosely  attached  at  this  point 
and  the  serum  passes  freely  under  it,  requiring  very  little  force  and 
producing  no  laceration  of  the  tissues  or  soreness  of  the  parts  suf- 
ficient to  interfere  with  the  child's  customary  position  in  bed.  If  the 
buttocks,  favorite  sites  for  the  injection,  are  selected,  the  needle  should 
be  inserted  well  upon  one  side,  so  as  not  to  interfere  with  the  resting 
posture  of  the  child. 

Before  injecting,  the  skin  should  be  thoroughly  scrubbed  with  green 
soap  and  washed  with  alcohol.  Upon  the  withdrawal  of  the  needle  the 
skin  should  again  be  washed  with  alcohol,  and  a  piece  of  zinc  oxid 
plaster,  one  inch  square,  applied  over  the  site  of  the  injection.  Under 
these  precautions  regarding  cleanliness  there  has  never  been,  in  my  ex- 
perience, a  suggestion  of  a  local  infection.  Wherever  the  site  of  the 
injection,  care  should  be  taken  not  to  plunge  the  needle  into  the  muscle, 
but  having  drawn  up  the  skin  between  the  fingers,  to  insert  the  needle 
horizontally. 

Late  Injection. — Antitoxin  should  always  be  given  in  diphtheria,  no 
matter  how  late  in  the  disease  the  case  may  first  be  seen.  In  one  case 
first  seen  by  me  on  the  sixth  day,  1 1,000  units  were  given.  The  child  re- 
covered. In  a  similar  case  I  would  now  give  20,000  units.  In  another 
case  of  laryngeal  diphtheria  in  a  boy  five  years  of  age  who  was  first 
seen  on  the  fifth  day  10,000  units  were  given,  with  prompt  recovery. 
In  a  similar  case  I  would  now  give  20,000  units  as  the  initial  dose 
and  repeat  if  necessary.  I  have  used  the  antitoxin  as  late  as  the  eighth 
day  of  the  disease,  with  resulting  benefit  or  recovery,  and  it  is  my  belief 
that  the  patient  would  not  have  recovered  without  antitoxin.  In  or- 
der to  be  signally  effective,  the  serum  should  be  given  not  later  than 
the  third  day.  The  later  it  is  given,  the  greater  the  amount  required, 
and  the  greater  the  need  of  repeating  the  injection. 

Immunization  and  Quarantine. — When  a  member  of  a  family  becomes 
ill  with  diphtheria,  the  suggestions  for  quarantine  (p.  649)  should 
be  carefully  followed.  In  every  case  of  diphtheria  other  children  of 
the  family  should  be  immunized.  Less  than  1000  units  should  never  be 
given  for  this  purpose,  regardless  of  the  age  of  the  child.  Cultures 
should  be  taken  from  the  throats  of  children  and  adults  alike.  If  the 
Klebs-Loffler  bacillus  is  found,  the  carrier  must  be  isolated  and  treated 
as  diphtheric,  so  far  as  quarantine  is  concerned.  Two  of  my  cases 
developed  diptheria  after  immunizing  doses  of  antitoxin.  A  child 
nine  months  of  age  was  given  3000  units  and  developed  diphtheria  four 
days  afterward.  This  patient  recovered  after  a  second  injection  of 
3000  units.  A  boy  four  years  of  age  was  given  1000  units  for  im- 
munization.    He  developed  diphtheria  in  thirty-six  hours,  which  was 


DIPHTHERIA  635 

controlled  by  the  injection  of  3000  units.  The  throat  was  clear  in 
forty-eight  hours  after  the  second  injection. 

Urticaria. — In  20  per  cent,  of  my  cases  urticaria  followed  the  use  of 
antitoxin.  The  earliest  appearance  of  the  eruption  was  on  the  fifth 
day  following  the  injection;  its  latest  appearance,  on  the  twenty-first 
day.  The  urticaria  apparently  differs  in  no  respect  from  that  due 
to  other  causes,  and  the  treatment  should  be  the  same.  Among 
local  applications,  a  1  per  cent,  solution  of  carboHc  acid  or  a  lead 
and  opium  wash  relieves  the  itching  better  than  do  other  measures. 
For  internal  administration,  salicylate  of  soda  answers  better  than 
any  other  form  of  medication.  To  a  child  five  years  old  three  grains 
well  diluted  may  be  given  every  two  hours  until  five  doses  have  been 
taken,  and  this  treatment  may  be  repeated  every  day  until  the  rash 
disappears. 

Remedial  Measures  Other  Than  Antitoxin. — Of  the  many  remedies 
which  have  been  advocated  and  used  from  time  to  time  in  the  treat- 
ment of  diphtheria,  practically  none  remains  in  use  at  the  present  time. 
During  the  pre-antitoxin  period  I  had  abundant  opportunity,  in  103 
cases  at  the  New  York  Infant  Asylum,  to  test  the  value  of  drugs,  in- 
halations, vaporizing  treatment,  local  applications,  gargles,  and  sprays. 
In  an  article  relating  to  this  epidemic  of  diphtheria  which  I  wrote 
several  years  ago  is  the  following  statement:  "The  death-rate  in  the 
institution  from  diphtheria  was  large — about  60  per  cent,  mortality. 
In  so  far  as  the  methods  of  treatment  were  concerned,  all  were  equally 
valueless.  The  mild  and  some  moderately  severe  cases  recovered 
under  good  general  management.  The  severe  cases  died  regardless 
of  treatment."  In  other  words,  there  was  no  method  or  scheme  of 
treatment  used  at  that  time  that  was  of  any  signal  value.  Happily, 
at  the  present  time,  all  the  old  methods  are  forgotten.  They  are  not 
needed.  Antitoxin  is  a  specific.  The  use  of  sprays  and  gargles  and 
applications  is  of  value  as  a  means  of  cleanliness  only.  For  this  pur- 
pose the  throat  irrigation  (p.  278)  answers  better  than  any  other  means. 
Forcible  irrigation  of  the  nose  should  not  be  employed.  In  such  cases 
the  danger  of  forcing  infected  material  into  the  Eustachian  tube,  with 
resulting  secondary  otitis,  is  real.  In  small  children,  if  the  breathing  is 
interfered  with  because  of  membrane  or  tenacious  secretions  in  the  nose, 
a  few  drops  of  Hquid  albolene  instilled  every  hour  will  give  as  much 
relief  as  can  be  furnished  by  any  other  local  measure. 

Sick-room  Regime. — In  the  management  of  diphtheria  the  same 
sick-room  regime  should  be  enforced  as  in  other  serious  diseases.  The 
temperature  of  the  room  should  never  be  above  70°F.,  and  at  all 
seasons  of  the  year  there  should  always  be  a  free  communication  with 
the  outer  air  by  means  of  an  open  window.  The  child  should  wear  the 
customary  night-clothes,  and  the  bed-clothes  should  be  of  the  same 
weight  as  those  used  in  health. 

Nourishment. — The  nutrition  of  the  patient  is  most  important.  As 
a  rule,  food  is  poorly  taken  because  of  the  pain  caused  by  swallowing. 
Inasmuch  as  but  a  few  ounces  may  be  taken  at  one  time,  the  nourish- 


636  THE    PRACTICE    OF    PEDIATRICS 

ment  may  well  be  given  in  as  concentrated  a  form  as  possible.  Milk 
should  be  given  as  the  chief  article  of  diet,  with  the  addition  of  Hme- 
water  or  bicarbonate  of  soda.  If  the  taste  of  milk  is  disagreeable  to 
the  patient,  it  may  be  mixed  with  equal  parts  of  a  thick  gruel  and  well 
salted.  Animal  broths  possess  so  little  nutriment  that  their  use  is 
unwise.  The  milk,  plain  or  diluted,  will  often  best  be  taken  if  given 
cold  or  cool,  even  to  children  under  one  year  of  age.  Fluid  will  usually 
also  be  taken  from  a  spoon  or  cup  better  than  from  a  bottle,  because 
of  the  discomfort  produced  by  drawing  on  the  nipple.  When  sufficient 
nourishment  will  not  be  swallowed,  gavage  (p.  790)  or  rectal  alimenta- 
tion assists  temporarily  in  maintaining  nutrition.  The  temperature  is 
rarely  high  enough  to  require  the  use  of  any  means  for  its  reduction. 
In  case  of  high  fever  the  sponge-bath  or  cool  pack  (p.  777)  will  answer 
the  requirements. 

Heart  Stimulants. — When  the  heart  action  becomes  weak,  irregular, 
or  intermittent,  stimulation  will  be  necessary.  For  this  purpose  three 
drugs  are  of  signal  value — strychnin,  tincture  of  strophanthus,  and 
alcohol. 

Laryngeal  Diphtheria. — ^Laryngeal  diphtheria  may  develop  coinci- 
dentally  with  a  tonsillar  or  faucial  diphtheria.  The  laryngeal  inflam- 
mation may  develop  secondarily  after  a  day  or  two  of  illness,  or 
it  may  be  the  first  manifestation  of  the  infection.  When  a  child  ill 
with  faucial  or  tonsillar  diphtheria  develops  a  hoarse  or  croupy  voice, 
with  or  without  impeded  respiration,  almost  invariably  the  larynx 
has  become  involved. 

Differential  Diagnosis. — When,  in  the  event  of  a  hoarse,  croupy 
voice  with  obstruction  as  the  manifestation  of  illness,  and  no  membrane 
is  visible,  it  is  by  no  means  easy  to  determine  whether  the  case  is  one  of 
membranous  laryngitis  or  acute  catarrhal  laryngitis.  The  following 
suggestions  have  aided  me  not  a  little  in  arriving  at  a  right  conclusion : 

Diphtheric  Membranous  Croup  Catarrhal  Croup 

Gradual  onset.  Obstruction  intermittent. 

Obstruction    persistent,    with   gradually  Sudden  onset, 
increasing  severity. 

Obstruction  both  to  inspiration  and  ex-  Obstruction  to  inspiration,  but  little  to 
piration.  expiration. 

Little  or  no  response  to  emetics  or  in- 
halations. Response  to  emetics  and  inhalations 

No  response  to  sedatives.  and  to  sedatives. 

The  mode  of  onset  is,  of  course,  not  to  be  relied  upon  absolutely  in 
differentiation.  Occasionally  the  onset  of  catarrhal  laryngitis  may  be 
gradual,  while  that  of  diphtheria  may  be  sudden.  In  the  consideration 
of  a  great  many  cases,  however,  the  points  of  differentiation  are  of  suffi- 
cient value  to  warrant  the  attention  which  has  been  given  them.  A 
particularly  valuable  sign  of  diphtheric  involvement  is  the  obstruction 
to  expiration  as  well  as  inspiration.  In  catarrhal  croup  there  is  obstruc- 
tion to  inspiration  only. 

Treatment. — A  safe  rule  to  follow,  in  view  of  the  urgent  demand  for 
early  injections  of  antitoxin,  is  the  same  as  in  other  forms  of  diphtheria, 


DIPHTHERIA  637 

i.  e.,  when  in  doubt,  inject  20,000  units.  From  the  gradual  cessation 
of  the  laryngeal  symptoms  it  is  fairly  safe  to  assume  that  the  child 
is  doing  well,  although  the  breathing  may  not  be  entirely  free  for 
forty-eight  or  seventy-two  hours  after  the  first  injection.  In  cases 
which  require  intubation  20,000  units  should  be  given  for  the  first 
injection  and  repeated  the  following  day.  According  to  my  observa- 
tion, intubation  cases  require  from  20,000  to  40,000  units,  even  when 
antitoxin  is  used  early,  by  which  we  understand  on  the  second  or  third 
day  of  the  disease.  The  earher  the  injection,  the  less  frequent  will  be 
the  necessity  for  its  repetition. 

Nasal  Diphtheria. — There  are  two  distinct  types  of  nasal  diphtheria 
— the  acute  and  the  chronic. 

The  acute  cases  resemble  in  all  respects  those  of  diphtheria  as  it 
occurs  in  the  throat  or  larynx  with  the  accompanying  clinical  mani- 
festations of  illness  and  prostration.  There  may  be  membrane  elsewhere 
and  in  many  of  the  cases  involving  the  throat  and  larynx  the  nares 
are  also  involved.  At  autopsies,  before  the  advent  of  antitoxin,  I  have 
repeatedly  seen  the  nasal  passages  plugged  throughout  their  entire 
extent,  the  membrane  being  continuous  from  the  anterior  nares  to 
beyond  the  first  bronchial  bifurcation. 

In  what  may  be  looked  upon  as  the  strictly  nasal  cases,  the  mucous 
membrane  of  one  or  both  nasal  passages  only  is  involved. 

Symptomatology. — A  symptom  pointing  strongly  to  a  Klebs-Loffler 
infection  of  the  mucous  membrane  of  the  nasal  passages  is  a  persistent 
excoriating  mucous  discharge,  with  or  without  a  tinge  of  blood.  The 
fever,  prostration,  and  other  evidence  of  the  infection  may  be  as  severe 
as  when  the  membrane  is  elsewhere  located. 

Diagnosis. — The  diagnosis  is  made  by  the  appearance  of  the  per- 
sistent excoriating  discharge,  by  the  discovery  of  false  membrane  in 
the  nasal  cavities,  and  by  the  finding  of  the  Klebs-Loffler  bacillus  in 
the  nasal  discharge. 

Treatment. — The  treatment  is  with  antitoxin,  as  suggested  for  the 
tonsillar  and  faucial  cases. 

Persistent  Nasal  Infection  with  the  Klebs-Loffler  Bacillus. — Per- 
sistent nasal  infection  of  a  mild  type  is  of  much  more  frequent  occur- 
rence than  is  generally  known.  These  cases  are  sometimes  alluded  to 
by  writers  under  the  term  "chronic  nasal  diphtheria." 

Symptoms. — The  child  has  a  persistent  nasal  discharge  from  one  or 
both  nostrils,  but  shows  no  sign  of  illness  other  than  that  occasioned  by 
the  persistent  rhinitis.  Since  there  are  no  systemic  effects,  these  are 
not  cases  of  diphtheria  in  the  accepted  sense  of  the  term.  Ulcerations 
are  occasionally  produced,  and  there  may  be  destruction  of  membrane, 
cartilage,  and  bone. 

Illustralive  Cases. — Case  1. — A  girl  of  eight  years  of  age  was  brought  to  my  office 
because  of  a  nasal  discharge  associated  with  considerable  obstruction.  The  child 
had  been  ill  for  about  one  week,  and  had  been  treated  for  grip  by  home  means. 
There  had  been  slight  fever  and  little  or  no  prostration,  but  a  serous  nasal  discharge 
which  was  bloody  at  times.  There  hod  been  one  or  two  severe  nasal  hemorrhages. 
An  examination  of  the  nasal  cavities  disclosed  that  both  were  filled  with  membrane, 


638  THE    PRACTICE    OF    PEDIATRICS 

pus,  and  blood.  Nasal  diphtheria  was  at  once  suspected,  and  a  culture  was  made 
which  was  negative.  During  the  following  three  days  six  cultures  in  all  were  made 
and  examined  by  three  different  bacteriologists  in  three  laboratories,  and  all  reports 
were  negative  for  the  IQebs-Loffler  bacillus.  The  membrane  was  removed  on  two 
occasions,  and  there  were  three  fairly  severe  nasal  hemorrhages  while  we  were  try- 
ing to  determine  the  nature  of  the  infection.  Various  local  measures  were  em- 
ployed without  in  any  way  influencing  the  process.  After  observing  the  case  one 
week,  during  which  time  the  child  remained  free  from  constitutional  disturbance  of 
any  nature,  I  gave  5000  units  of  antitoxin.  In  twenty-four  hours  the  nose  was 
clear  and  only  a  considerable  erosion  on  the  septum  remained,  which  promised  to 
give  trouble  because  of  its  depth  and  tendency  to  bleed.  This  area  was  cauterized 
and  healed  promptly,  and  the  child  was  then  well. 

Interesting  is  this  case  in  view  of  the  cultural  absence  of  the  Klebs-LofBer 
bacillus,  and  the  prompt  response  to  antitoxin,  which  proved  beyond  doubt  that 
the  case  was  one  of  diphtheria. 

Case  2. — A  strong,  robust  boy,  twelve  years  old,  from  a  New  York  suburb,  con- 
sulted me  solely  on  account  of  inability  to  breathe  through  his  nose  and  a  night- 
cough  which  was  quite  severe.  Examination  of  the  nose  showed  it  to  be  filled  with 
crusts,  pus,  and  dried  blood.  Upon  removing  the  obstruction  a  bleeding  surface 
was  left  on  both  sides,  and  a  perforation  of  the  septum,  the  size  of  a  dime,  was  found 
posteriorly.  _  A  culture  was  taken  and  showed  a  pure  growth  of  the  Klebs-Loffler 
bacillus.  Five  thousand  units  of  antitoxin  were  given.  The  condition  immediately 
improved.  Within  four  days  the  nose  was  free  from  the  Klebs-Loffler  bacillus. 
This  condition  had  existed  for  at  least  a  year,  and  the  boy  had  been  examined  by  a 
specialist. 

Case  3. — A  girl  four  years  of  age  became  ill  with  fever,  which  persisted  for  thirty- 
six  hours,  when  the  attending  physician  noticed  a  swelling  and  edematous  condition 
of  the  soft  palate.  On  seeing  the  case  forty-eight  hours  after  the  onset  I  found  the 
swelling  and  edema  still  present,  with  considerable  post-nasal  discharge.  At  no 
time  was  membrane  visible.  A  culture  was  taken  which  proved  negative.  Five 
thousand  units  of  antitoxin  were  given,  and  the  child  made  a  prompt  recovery  in. 
about  forty-eight  hours.  While  there  is  no  direct  proof  that  the  child  had  diphtheria, 
the  prompt  recovery  after  antitoxin  suggests  this  condition.  The  absence  of  cul- 
tural proof,  in  view  of  our  experience  in  the  first  case  recounted,  does  not  signify 
that  the  infection  did  not  exist. 

Case  4. — A  mother  consulted  me  concerning  her  two  children  aged  2  and  4 
years,  both  of  whom  had  had  a  chronic  cold  in  the  head  for  six  weeks.  There 
was  a  persistent  nasal  discharge  from  both  nostrils  in  each  patient,  serous  in 
character,  requiring  several  handkerchiefs  daily.  The  children  were  entirely 
well  and  happy.  A  culture  showed  Klebs-Loffler  bacilli  in  both  patients.  Five 
thousand  units  of  antitoxin  for  each  child  controlled  the  discharge. 

Much  remains  to  be  learned  regarding  the  Klebs-Loffler  bacillus 
and  its  action  upon  the  individual.  The  effects  of  this  organism  may 
be  entirely  local.  Every  year  in  hospital  work  we  see  many  of  these 
cases.  In  private  they  are  less  frequently  encountered.  On  the  other 
hand,  what  is  apparently  the  same  organism,  with  the  same  morphologic 
characteristics,  may  produce  not  only  local  effects  but  the  most  pro- 
found systemic  toxemia  and  death. 

In  the  cases  with  local  manifestations,  are  we  dealing  with  the  Klebs- 
Loffler  bacillus  in  an  attenuated  form,  or  is  the  infection  of  a  different 
nature  and  due  to  another  organism  of  the  same  family?  Is  it  possible 
for  the  cases  showing  only  local  manifestations  to  transmit  the  disease 
to  others  with  resulting  systemic  effects?  I  have  never  known  of  such 
an  occurrence. 

Treatment. — In  these  cases  usually  one  dose  of  5000  units  of  anti- 
toxin is  sufficient.  In  case  the  process  is  not  controlled,  this  dose 
should  be  repeated. 

Intubation. — To  the  genius  of  the  late  Dr.  Joseph  O'Dwyer,  of  New 
York,  is  due  the  perfecting  of  this  operation,  which  will  forever  stand 


DIPHTHERIA  639 

as  a  monument  to  the  inestimable  service  which  he  rendered  to  man- 
kind. The  O'Dwyer  intubation  set  (Fig.  88)  furnishes  us  with  the 
necessary  instruments  for  the  operation.  Various  modifications 
of  the  tubes,  the  introductor,  and  the  retractor  have  been  attempted 
from  time  to  time  by  others,  but  the  original  perfected  design  of 
O'Dwyer  has  yet  to  be  improved  upon. 


Fig.  86.— Extubator. 

Intubation  of  the  larynx  may  be  required  in  case  of  a  retropharyn- 
geal abscess  situated  low  on  the  posterior  pharyngeal  wall,  edema  of  the 
larynx  or  acute  laryngitis.  The  greatest  usefulness  of  the  operation, 
however, — that  for  which  it  was  designed, — is  to  relieve  the  stenosis  of 
laryngeal  diphtheria.  Before  attempting  to  introduce  a  tube  into  the 
larynx  of  the  Kving  subject  the  physician  should  familiarize  himself 
with  the  operation  on  the  cadaver.  In  no  other  way  can  the  procedure 
safely  be  learned.     Attempts  at  intubations  by  the  unskilled  on  the  liv- 


Introductor  with  tube  attached. 


ing  subject  can  result  only  in  laceration  and  other  gross  injuries  to  the 
parts. 

Indications. — When  to  intubate  is  a  question  puzzling  alike  to  stu- 
dents and  to  many  physicians.  It  has  been  variously  answered,  and 
many  attempts  have  been  made  to  formulate  a  series  of  clinical  mani- 
festations the  presence  of  which  would  render  the  operatiion  necessary. 
Thus,  it  has  been  said  to  be  indicated  when  there  is  a  pronounced  reces- 
sion of  the  suprasternal  and  infrasternal  regions,  and  when,  as  a  result 


640 


THE    PRACTICE    OF   PEDIATRICS 


of  stenosis,  air  enters  the  bases  of  the  lungs  but  feebly  or  not  at  all.  It 
maj^  safely  be  said  that  intubation  is  never  done  too  early,  but  it  is  very 
apt  to  be  done  too  late — not  too  late  in  a  great  majority  of  instances 
to  be  of  some  service  to  the  patient,  but  too  late  to  be  of  the  greatest 
possible  service.  My  rule  regarding  intubation  in  laryngeal  diph- 
theria is  to  intubate  when  I  see  that  the  child  is  wasting  vitality  in  his 
efforts  to  carry  on  respiration.  Intubation  should  not  be  postponed 
until  he  becomes  exhausted  in  the  struggle  for  air.  Diphtheria  is  a 
disease  in  which  every  possible  strength-unit  must  be  preserved. 
Energy  wasted  in  supplying  air  is  an  unnecessary  waste,  since  O  'Dwyer 
has  shown  us  how  to  introduce  a  tube  into  the  larynx. 


Fig.  88. — O'Dwyer  intubation  set. 

Operation. — For  the  operation  of  intubation, 'the  patient  should  be 
wrapped  from  his  shoulders  to  his  feet  in  a  sheet  securely  pinned  from 
top  to  bottom.  The  older  and  stronger  the  child,  the  more  this  is  neces- 
sary (Fig.  89) .  The  patient  is  held  on  the  lap  of  the  nurse,  who  passes 
her  right  hand  around  the  child 's  body.  The  child 's  head  rests  on  the 
nurse 's  right  shoulder,  firmly  held  in  position  by  her  left  hand.  If  the 
child  be  large  and  strong,  a  third  person  may  be  required  to  hold  the 
head.  After  the  gag  is  in  position,  the  operator,  with  instruments  and 
hands  disinfected,  holds  the  introductor  in  his  right  hand,  locates  the 
glottis  with  the  forefinger  of  the  left,  and,  using  it  as  a  guide,  directs 
the  tip  of  the  tube  into  the  larynx.  He  must  be  certain  that  the  tip  is 
properly  placed  before  exerting  pressure  to  put  the  tube  into  position. 
This  can  readily  be  appreciated  by  one  who  has  practised  on  the 
cadaver.    When  the  tip  of  the  tube  positively  is  engaged  in  the  glottis, 


DIPHTHERIA 


641 


gentle  pressure  will  put  it  into  final  position.  Force  should  never  be 
used,  even  when  the  tube  is  started  right,  for  the  child  may  require  a 
smaller  tube  than  his  age  indicates.  This  is  rather  unusual,  however, 
as  are  the  cases  which  require  larger  tubes  than  the  age  calls  for.  When 
the  tube  is  easily  coughed  up,  it  is  my  custom  to  introduce  the  next 
larger  size.  With  the  tube  in  position,  the  obturator  is  quickly 
removed.  I  never  trust  to  pressure  on  the  shank  of  the  introductor 
to  disengage  the  obturator,  but  keep  the  guiding  index-finger  of  the 
left  hand  on  the  expanded  head  of  the  tube  in  order  to  insure  its 
remaining  in  position  during  the  extraction  of  the  obturator. 


Fig.  89. — Position  for  intubation. 

Results  of  Intubation. — After  the  operation  the  child  who  has  pre- 
viously been  struggling  will  take  a  deep  inspiration  and  cough.  One  of 
the  most  welcome  sounds  to  the  operator  is  the  sharp  rattle  produced 
by  the  passage  of  air  through  the  mucus  which  has  been  forced  into  the 
tube.  This  tells  him  that  the  tube  is  in  position  and  that  speedy  relief 
of  the  stenosis  may  be  expected.  The  intubated  child  will  usually 
cough  vigorously  for  several  minutes,  and  in  so  doing  maj^  bring  up  a 
quantity  of  mucus  and  shreds  of  membrane.  I  have  often  been  as- 
tonished at  the  large  pieces  of  membrane  and  the  quantity  of  thick 
41 


642  THE    PRACTICE    OF    PEDIATRICS 

mucus  that  can  pass  through  the  comparatively  small  lumen  of  the 
tube.  In  a  few  cases  the  presence  of  the  tube  in  the  larynx  has  caused 
such  a  persistent  cough  that  a  sedative  was  required  to  control  it. 
Small  doses  of  bromid  of  soda — ^four  grains  every  half-hour  for  two  or 
three  hours,  for  a  child  four  years  of  age — usually  answer  the  purpose. 
The  thread,  looped  and  knotted,  which  has  been  attached  to  the  tube, 
should  be  long  enough  to  extend  four  or  five  inches  beyond  the  lips.  In 
case  relief  to  the  stenosis  is  not  immediately  perceptible  after  the  opera- 
tion, or  if  the  breathing  is  made  more  difficult,  one  may  be  sure  either 
that  the  tube  is  not  in  position  or,  if  in  position,  that  it  is  plugged  with 
membrane,  or  that  membrane  may  have  become  disengaged  and  is 
pushed  downward  ahead  of  the  tube.  A  tube  in  the  esophagus,  where, 
in  my  hospital  service,  I  have  seen  it  placed  by  interns,  may  exert 
sufficient  pressure  upon  the  posterior  portion  of  the  larynx  effectually 
to  impede  respiration. 

Illustrative  Case. — Several  years  ago  I  was  called  to  intubate  a  boy  two  years 
of  age  who  was  suffering  from  moderate  stenosis  due  to  diphtheria.  The  tube  was 
easily  introduced,  but  its  introduction  was  followed  by  entire  cessation  of  respira- 
tion. The  tube  was  immediately  extracted  by  means  of  the  attached  thread  and 
was  found  to  be  plugged  with  membrane  requiring  considerable  pressure  with  a 
wooden  toothpick  to  dislodge  it.  The  stenosis  was  somewhat  relieved  as  the 
result  of  dilating  the  parts  and  a  removal  of  a  portion  of  the  membrane,  but  not 
sufficiently  to  furnish  permanent  relief  to  the  patient.  The  tube  was  again  intro- 
duced, followed  by  a  complete  relief  of  the  stenosis. 

Displacement  of  the  Membrane. — When  membrane  is  dislodged  and 
pushed  ahead  of  the  tube,  it  will  usually  be  expelled  by  coughing  after 
the  extraction  of  the  tube. 

Illustrative  Case. — A  case  of  this  nature,  following  the  withdrawal  of  the  obtura- 
tor, occurred  in  a  child  six  years  of  age,  whose  breathing,  before  difficult,  was  im- 
possible. The  child  struggled  violently,  became  much  excited,  and  with  one  hand 
free,  knocked  the  gag  from  its  mouth.  In  my  efforts  to  extract'the  tube  the  string 
broke,  and  while  introducing  the  gag  in  order  to  use  the  extractor,  the  child's  strug- 
gles and  attempts  at  coughing  dislodged  both  the  tube  and  a  large  amount  of 
membrane,  one  piece  of  which,  inclosing  the  tube,  came  out  as  a  perfect  cast  of 
the  larynx  and  upper  trachea.  The  relief  was  immediate.  Reintubation  was  not 
attempted,  nor  was  it  later  necessary.  The  child  had  been  given  5000  units  of 
antitoxin  twenty-four  hours  before,  which  helps  to  explain  the  dislodgment  of  the 
membraae. 

Removal  of  the  Tube. — When  the  patient  is  progressing  satisfactorily, 
the  question  arises:  How  soon  may  the  tube  be  removed?  I  rarely 
remove  it  before  the  fourth  day  after  intubation.  I  find  that  when  it 
is  taken  out  on  the  second  or  third  day,  for  cleansing  or  other  purposes, 
it  must  usually  be  replaced. 

Necessity  for  Intubation. — With  the  introduction  of  antitoxin,  the 
necessity  for  intubation  has  become  less  frequent.  The  free  use  of  anti- 
toxin,— 10,000  to  30,000  units  as  an  initial  dose, — given  with  the  first 
sign  of  obstruction,  and  repeated  at  eight-hour  intervals  until  two,  three, 
or  more  doses  have  been  given,  will  render  intubation  a  still  rarer  neces- 
sity. I  do  not  feel  safe  in  these  cases  until  15,000  or  20,000  units  have 
been  given.  Fortunately,  in  laryngeal  obstruction  due  to  diphtheria 
the  stenosis  is  usually  of  gradually  increasing  severity,  so  that  by  the 


SCABLET    FEVER    (sCARLATINA)  643 

early  use  of  antitoxin  many  cases  are  relieved  before  the  necessity  for 
operation  arises. 

SCARLET  FEVER  (SCARLATINA) 

Scarlet  fever  has  been  clearly  recognized  for  many  centuries  although 
its  early  history  is  exceedingly  obscure.  The  disease  has  always  been 
most  prevalent  in  civilized  portions  of  the  world,  has  shown  remarkable 
differences  in  the  severity  of  its  separate  outbreaks,  and  in  almost  all 
instances  notably  refrained  from  attacking  a  certain  proportion  of 
exposed  individuals,  in  this  respect  contrasting  sharply  with  measles, 
which  exhibits  no  such  selectiveness. 

Jurgensen  has  reported  an  epidemic  which  in  the  years  1873  to  1875 
ravaged  the  Faroe  Islands,  where  for  at  least  half  a  century  the  inhabi- 
tants had  not  been  exposed  to  the  disease  and  where  the  geographic 
conditions  rendered  observations  on  its  course  unusually  easy.  Here 
the  discovery  was  made  that,  from  a  population  comprising  all  ages  and 
certainly  not  protected  against  scarlatina  by  a  previous  attack,  only 
38.3  per  cent,  suffered  from  the  epidemic,  whereas  a  similar  study  of 
measles  in  the  same  locality  showed  that  99  per  cent,  of  the  population 
unprotected  by  previous  infection  were  attacked.  It  was  furthermore 
observed  that  the  susceptibility  to  scarlet  fever  was  about  seven  times 
greater  in  persons  under  twenty  than  in  those  over  forty. 

The  records  of  certain  European  epidemics  exhibit  a  mortality  as 
high  as  30  per  cent.,  contrasting  with  a  rate  as  low  as  3  per  cent,  for  the 
same  place  at  another  period.  In  New  York  State  scarlet  fever  easily 
ranks  among  the  dozen  most  prominent  causes  of  death,  usually  causing 
a  comparative  mortality  of  five,  to  four  of  measles  and  six  of  typhoid. 

Recent  studies  of  the  disease  have  been  devoted  extensively  to  a 
search  for  the  specific  cause,  our  ignorance  regarding  which  is  now  the 
most  serious  obstacle  in  the  management  of  cases. 

Etiology. — The  specific  etiologic  factor  in  scarlet  fever  has  not  yet 
been  isolated.  It  is  apparently  present  in  the  blood,  throat,  desquamat- 
ing scales,  and  discharges  from  complicating  otitis  and  other  suppura- 
tions. Inclusions  in  the  polymorphonuclear  leukocytes  have  recently 
been  described  as  found  in  30  cases  of  scarlet  fever  by  Dohle,  and  con- 
firmed by  Kretschmar  and  by  Nicoll  and  Williams.  The  inclusions 
would  seem,  however,  to  be  non-specific,  since  they  are  present  in  cases 
of  other  streptococcal  infections. 

Positive  inoculations  of  scarlet  fever  into  chimpanzees  have  been 
reported  by  Landsteiner,  Levaditi  and  Prosek,  and  positive  experi- 
ments with  lower  monkeys  by  Bernhardt.  These  results,  as  yet, 
lack  confirmation. 

Bacteriology. — Streptococci  are  found  in  the  throat  almost  invari- 
ably in  the  early  stages  of  scarlet  fever,  and  they  may  be  present  in  the 
blood  and  lymph-nodes  late  in  the  disease  or  after  death.  Kolmer's 
studies  show  that  the  streptococci  found  in  scarlet  fever  are  not  specific 
in  their  serum  reactions,  and  Weaver  found  that  they  are  morphologic- 
ally and  culturally  like  streptococci  isolated  from  lesions  other  than 


644  THE    PRACTICE    OF    PEDIATRICS 

those  of  scarlet  fever  The  role  of  this  coccus  is  probably  that  of  a 
secondary  or  accompanying  invader,  causing  or  increasing  the  sup- 
purative complication.  Mallory  has  recently  found  a  Gram  positive 
bacillus  at  the  seat  of  the  primary  lesion  in  cases  of  scarlet  fever,  and 
calls  the  organism  B.  scarlatinal.  Definite  proof  of  its  etiological 
relationship  to  the  disease  is  lacking. 

Transmission. — Scarlet  fever  is  usually  transmitted  through  asso- 
ciation of  the  diseased  with  the  unprotected.  There  seems  to  be  sub- 
stantial ground  for  the  belief  that  the  contagion  may  be  carried  by  an 
intermediary.  This  probably  is  of  rare  occurrence.  Milk  may  be 
a  means  of  conveyance. 

Contagion. — It  has  been  proven  that  it  is  among  the  least  con- 
tagious of  the  contagious  diseases.  I  have  repeatedly  known  a  child  to 
develop  scarlet  fever  in  a  ward  with  several  others,  none  of  whom 
later  developed  the  disease,  as  they  were  confined  to  their  beds,  and 
consequently  kept  from  any  immediate  contact  with  the  patient. 

The  most  contagious  period  is  during  the  first  three  or  four  days  of 
the  illness.  The  danger  of  transmission  during  the  period  of  desquama- 
tion is  much  less  than  is  generally  believed.  Since  little  or  nothing  of 
the  nature  of  the  infecting  agent  is  known,  it  is  not  wise  to  make  defi- 
nite statements  respecting  the  period  of  communicability.  My  obser- 
vation, however,  in  a  great  many  cases  in  institutions  and  in  private 
work,  leads  me  to  believe  that  the  desquamation  will  some  day  be 
proved  to  be  seldom,  if  ever,  a  carrier  of  the  disease.  Of  late,  many 
authors  are  inclined  to  place  less  emphasis  upon  the  possible  conta- 
gion from  cutaneous  scales  and  more  upon  the  infective  character  of 
the  nasal  and  aural  discharges. 

Evidence  is  at  hand  showing  that  books,  clothing,  flowers,  and  food- 
stuffs are  means  of  conveyance  from  the  diseased  to  the  unprotected. 
From  my  own  observation,  I  have  never  known  of  a  case  having  been 
contracted  in  any  of  these  ways.  I  have,  however,  seen  a  great  many 
cases  of  scarlet  fever  which,  ordinarily,  would  have  passed  undiagnosed 
if  the  patient  had  not  been  suspected  because  of  exposure.  I  see  cases 
frequently  in  which  a  positive  immediate  diagnosis  is  quite  impossible. 

Illustrative  Case. — During  the  visitation  of  scarlet  fever  to  a  family,  four  chil- 
dren were  attacked.  Dr.  S.  Finley  Bell  had  treated  the  two  other  members  of  the 
family  at  Englewood,  a  suburb  of  New  York.  A  trained  nurse  caring  for  the  chil- 
dren contracted  the  disease  and  died.  Later,  a  girl  six  years  old  died  with  the 
disease.  On  one  of  my  visits  to  one  of  the  children  who  had  been  sent  to  New 
York  city  and  later  developed  the  disease,  a  member  of  the  family  called  my  atten- 
tion to  the  arms  of  the  laundress,  which  were  slightly  reddened.  It  was  Monday 
morning  and  she  was  washing.  She  had  no  temperature,  a  normal  throat,  no  rash 
except  upon  the  arms,  and  felt  well  and  was  annoyed  that  she  should  be_  disturbed 
in  her  work.  The  redness  of  the  arms  disappeared  after  the  completion  of  the 
washing,  and  nothing  further  was  discovered  until  two  weeks  later,  when  she  was 
found  to  be  desquamating  profusely  on  the  hands  and  feet  and  slightly  over  the 
body  generally.  She  was  sent  to  the  Willard  Parker  Hospital,  where  she  required 
two  weeks  to  complete  the  desquamation.  Here  was  a  case  in  which  a  most  care- 
ful search  failed  to  reveal  any  conclusive  evidence  of  scarlet  fever,  and  yet  the 
woman  had  the  disease  at  the  time  of  examination. 

There  is  strong  probability  that  many  of  the  cases  of  obscure  origin 


SCARLET    FEVER    (sCARLATINA)  645 

are  contracted  by  exposure  to  such  atypical  cases,  rather  than  through 
infected  milk,  books,  articles  of  clothing,  or  intermediary  human 
carriers. 

Susceptibility. — The  most  susceptible  age  is  from  the  second  to  the 
twelfth  year.  Cases  occurring  in  children  under  one  year  old  are  rare. 
The  very  young  appear  to  possess  a  distinct  immunity. 

Illustrative  Case. — During  an  epidemic  at  the  New  York  Infant  Asylum  at  Mt. 
Vernon,  N.  Y.,  a  colored  boy  was  found  to  have  the  disease  in  a  very  active  form. 
The  institution  was  built  on  the  cottage  plan  and  this  boy,  28  runabout  children, 
and  4  nursing  women  orderlies  with  their  4  nurslings  occupied  the  ward  on  a  second 
floor  in  one  of  the  two-story  cottages.  The  institution,  comprising  400  children 
and  about  200  women,  was  crowded. 

To  break  up  the  ward  would  have  meant  that  the  exposed  children,  some  of 
whom  would  probably  develop  scarlet  fever,  would  be  placed  with  unprotected  and 
unexposed  children.  It  was,  therefore,  decided  to  quarantine  the  ward  with  its  in- 
mates. Every  child  in  this  ward  developed  scarlet  fever  except  the  four  nurslings, 
who  at  the  time  of  the  outbreak  were  under  three  months  of  age.  Three  of  the 
women  also  escaped.  The  fourth  woman  developed  the  disease  and  had  a  mode- 
rately severe  attack,  during  which  time  she  nursed  her  infant,  which  remained  well. 
It  is  of  interest  that  so  effective  was  the  quarantine  that  the  disease  did  not  spread 
beyond  the  ward  in  which  it  developed. 

Second  Attacks. — One  attack  almost  always  protects  from  subse- 
quent attacks.  I  have  seen  but  two  undoubted  instances  of  a  second 
attack,  one  of  which  occurred  after  an  interval  of  four  months  in  a  boy 
of  six  years,  the  child  dying  on  the  fifth  day  of  the  illness ;  the  other  in  a 
girl  twelve  years  of  age,  whose  previous  attack  was  four  years  earlier. 
In  the  girl  the  second  attack  ran  a  typical  but  uneventful  course. 

It  is  interesting  to  note  that  an  unprotected  individual  may  be 
repeatedly  exposed  and  only  at  a  late  period  develop  the  disease.  Thus, 
during  an  intern  service  in  the  institution  referred  to,  where  I  cared  for 
108  cases  of  scarlet  fever,  and  the  epidemic  was  severe,  requiring  that 
many  children  be  seen  several  times  a  day,  three  months  of  daily  and 
sometimes  hourly  exposure  transpired  before  the  unmistakable  signs 
of  the  disease  became  manifest  in  me. 

Incubation. — The  period  of  incubation  is  variable.  It  is  rarely  less 
than  five  days.  If  an  exposed  child  passes  the  ninth  day  in  safety,  the 
disease  will  probably  not  develop  later.  I  have  known  one  case  to 
develop  after  twelve  days'  exposure,  and  one  on  the  fourteenth  day 
following  exposure.  So  long  a  period  of  incubation,  however,  is  exceed- 
ingly rare.  Cases  reported  as  developing  after  a  very  long  exposure, — ■ 
three  to  four  weeks, — result  from  later  exposure  which  was  not  known. 

Symptomatology. — Nearly  all  the  characteristics  of  the  disease  are 
subject  to  wide  variations.  Even  the  rash,  the  most  constant  symp- 
tom, may  be  simulated  by  sepsis  or  produced  by  drugs.  Among  the 
diseases  of  children  which  we  are  called  upon  to  treat  there  is,  further- 
more, none  other  which  may  present  itself  in  such  unusual  and  peculiar 
ways. 

The  three  symptoms  upon  which  some  reliance  may  be  placed  are 
fever^  angina,  and  the  rash.  Anyone  of  these,  however, maybe  absent 
in  the  mild  cases.  In  the  moderately  severe  cases  the  onset  is  usually 
abrupt,  with  fever,  angina,  prostration,  and  vomiting,  and  after  twenty 


646  THE    PRACTICE    OF    PEDIATRICS 

four  to  twenty-eight  hours  the  developing  rash,  which  is  usually 
fairly  characteristic.  The  angina  causes  a  diffuse  redness  of  the  mucous 
membrane  of  the  fauces  and  tonsils,  and  on  the  soft  palate  above  the 
uvula  minute  red  points  become  visible  which  may  coalesce,  forming 
diffuse,  small,  injected  areas,  and  producing  a  blotched  appearance. 

There  is  loss  of  appetite  and  always  thirst.  The  child  is  irritable, 
and  if  old  enough,  complains  of  headache  and  muscle  soreness.  The 
temperature  furnishes  a  fairly  accurate  index  of  the  severity  of  the  dis- 
ease. The  mild'cases  have  little  fever,  while  the  severe  cases  almost 
always  have  a  high  temperature.  Thus  a  temperature  range  from  103° 
to  105°F.  will  usually  be  accompanied  by  a  well-marked  rash  and  pros- 
tration, which  tell  us  that  the  poisoning  is  severe.  When  the  tempera- 
ture remains  above  103°F.,  the  child  is  very  uncomfortable  and  com- 
plains much  of  itching. 

The  eruption  remains  at  its  height  from  two  to  six  days,  which  may 
be  looked  upon  as  the  period  of  the  rash.  With  a  subsidence  of  the 
rash,  the  temperature  falls  gradually  to  normal. 

Desquamation. — Coincident  with  the  fading  of  the  rash  the  des- 
quamation usually  begins.  It  may  be  delayed,  however,  from  this 
time  until  the  third  or  fourth  week.  In  a  very  few  cases  I  have  known 
the  rash  to  last  longer  than  the  tenth  day.  It  may  show  great  irreg- 
ularity in  its  duration. 

Illustrative  Case. — During  our  epidemic  of  scarlet  fever  every  child  in  the  in- 
stitution was  carefully  inspected  three  times  daily.  At  o  p.  m.,  the  time  of  the  last 
inspection  for  the  day,  a  boy  of  two  years  had  a  temperature  of  102°F.,  an  unmis- 
takable rash  over  the  left  buttock  and  thigh,  and  some  redness  of  the  throat.  There 
was  but  little  prostration.  He  was  quarantined,  and  six  hours  after  his  isolation 
the  rash  faded  absolutely.  His  fever  promptly  subsided  on  the  same  day.  In 
spite  of  the  suspicion  of  a  mistake  in  diagnosis,  inasmuch  as  he  had  been  placed  in 
a  scarlet  fever  ward  and  exposed,  we  had  to  keep  him  there.  Greatly  to  our 
surprise,  on  the  tenth  day  free  desquamation  began. 

When  uncomplicated,  the  average  case  goes  on  to  recovery,  with 
completed  desquamation  in  from  two  to  four  weeks. 

The  shedding  of  dead  epidermis  may  be  most  variable  in  its  mani- 
festations. I  have  seen  the  skin  of  the  hands  and  feet  shed  like  a 
glove  "en  masse,"  and  I  have  seen  one  case  in  which  the  rash  was 
equally  well  marked  in  which  there  was  no  desquamation  of  any  nature 
at  any  time.  There  has  been  desquamation,  however,  although  it  may 
be  very  slight,  in  nearly  all  scarlet  fever  cases  coming  under  my  obser- 
vation. There  may  be  but  slight  peeling  of  the  fingers  and  toes. 
The  heel  and  the  anterior  aspect  of  the  fingers  and  toes  are  the  sites 
usually  selected  when  the  desquamation  is  scanty. 

Second  Desquamation. — I  have  seen  but  two  cases  of  second  des- 
quamation. The  first  patient  was  a  girl  of  five  years,  who  completed 
the  first  desquamation  and  was  free  for  six  weeks,  when  the  desquama- 
tion again  occurred  on  the  hands  and  feet  and  required  three  weeks  for 
its  completion.  In  the  other  case,  that  of  a  girl  twelve  years  of  age, 
the  second  desquamation  appeared  three  weeks  after  the  completion 
of  the  first.     It  involved  only  the  feet  and  was  of  two  weeks'  duration. 


SCARLET    FEVER    (sCARLATINA)  647 

The  amount  of  desquamation  bears  a  fairly  definite  relation  to  the 
severity  of  the  rash,  excepting  in  the  anomalous  cases. 

Severity. — The  illness  may  be  of  the  mildest  type,  and  impossible  of 
positive  diagnosis,  or  it  may  be  so  severe  that  the  child  will  live  only  a 
few  hours.  My  shortest  fatal  case  lasted  thirty-six  hours  from  the  on- 
set of  the  symptoms.  The  child  was  never  conscious  after  the  first 
invasion,  and  the  temperature  was  never  below  106°F.,  nor  could  it  be 
reduced  below  this  point. 

Such  cases  as  these,  in  which  the  system  is  absolutely  overpowered 
by  the  scarlet  fever  poison,  are  extremely  rare.  The  disease,  when 
fatal,  is  usually  so  through  its  complications. 

It  has  not  been  my  observation  that  the  presence  of  wounds  in  any 
portion  of  the  body  renders  a  person  more  liable  to  scarlet  fever. 

Diagnosis. — The  diagnosis  in  many  cases  is  very  easy.  In  some  it 
is  difficult,  and  in  others  impossible.  We  have  no  positive  means  of 
proving  our  case  clinically  or  bacteriologically.  Not  only  are  the  mild 
cases  difficult  of  diagnosis,  but  also  the  very  severe  cases.  In  malig- 
nant cases  the  patient  may  die  before  the  development  of  characteristic 
signs,  or  the  signs  may  be  so  masked  by  the  severity  of  the  infection  as 
to  render  diagnosis  impossible. 

Our  means  of  diagnosis  are  the  angina,  which  occasions  a  diffuse, 
intense  general  redness  of  the  throat,  the  fever,  and  the  diffuse  blush  of 
the  skin,  which  in  twelve  or  twenty-four  hours  develops  into  a  diffuse 
punctate  rash  usually  appearing  first  and  most  characteristically  over 
the  lower  abdomen,  in  the  groin,  on  the  inner  aspect  of  the  thighs,  and 
over  the  buttocks,  and  thence  extending  to,  and  involving,  the  entire 
skin  surface. 

It  has  not  been  my  observation  that  the  rash  first  appears  on  the 
neck  and  chest,  as  has  been  claimed  by  different  writers.  The  so-called 
strawberry  tongue  is  of  no  differential  value,  for  it  may  occur  in  many 
other  forms  of  illness. 

Complications. — Probably  no  other  disease  of  infancy  or  childhood 
is  so  fertile  in  serious  complications  as  scarlet  fever.  In  fact,  compara- 
tively few  die  from  the  direct  effects  of  the  scarlet  fever  poison.  A 
streptococcus  infection  of  the  throat  is  present  in  all  cases  of  any  degree 
of  severity.  This  I  have  demonstrated  in  dozens  of  cases,  and  it  is  the 
throat  as  a  culture  field  for  the  streptococcus  that  is  the  great  source  of 
danger  in  the  disease. 

Membranous  non-diphtheric  angina  has  always  been  of  streptococcal 
origin  in  my  cases.  On  inspection,  the  exudation  resembles  that  of 
true  diphtheria  and  our  only  means  of  differentiation  is  the  making  of  a 
culture.  Such  a  membrane  may  involve  the  nasal  passages,  but  rarely 
extends  to  the  larynx.  I  have  seen  but  two  cases  of  membranous 
laryngitis  of  proved  streptococcal  origin,  and  these  were  not  in  scarlet 
fever  patients.  The  local  infection  may  be  sufficiently  severe  to  cause 
extreme  necrosis. 

Ilhistrative  Cases. — In  one  case  I  had  been  engaged  to  remove  a  pair  of  very 
large  tonsils.     This  boy  developed  a  very  severe  scarlet  fever  before  the  time 


648  THE    PRACTICE    OF    PEDIATRICS 

appointed  for  the  operation.     On  his  recovery  the  throat  was  as  free  of  tonsil 
tissues  as  if  they  had  been  carefully  enucleated. 

In  a  fatal  case  necrosis  of  the  soft  palate  occurred,  resulting  in  a  perforating 
ulcer  larger  than  a  dime. 

True  diphtheria  occurs  as  a  complication  in  a  very  small  percentage 
of  the  cases  of  scarlet  fever.  Before  our  knowledge  of  the  Klebs- 
Loffler  bacillus,  much  was  heard  of  diphtheria  as  complicating  scarlet 
fever,  and  this  because  of  the  presence  on  the  tonsils  of  membrane, 
which  we  now  know  to  be  of  streptococcal  origin. 

Adenitis. — From  the  throat  the  glands  may  be  infected.  The 
lymphatic  glands  at  the  angle  of  the  jaw  and  the  retropharyngeal 
glands  are,  by  reason  of  their  location,  the  most  frequently  involved. 
Suppuration  of  the  glands  and  abscess  are  very  frequent  results,  and 
diffuse  edematous  cellulitis  of  the  neck  is  an  occasional  result  of  such 
infection. 

Cases  have  been  reported  in  which  the  pus  burrowed  into  the  medi- 
astinum, causing  septic  endocarditis  and  empyema. 

Pericarditis  and  endocarditis  have  been  very  rare  complications  in 
my  cases,  and  have  always  been  fatal,  for  the  reason  that  such  cases  are 
always  purulent,  of  streptococcal  origin.  I  have  had  cases  when  it 
seemed  that  there  must  be  an  endocarditis,  but  which  recovered  entirely 
too  promptly  to  have  had  this  complication.  In  these  instances  there 
probably  was  an  acute  dilatation  which  had  given  rise  to  the  murmur. 

Myocarditis  of  a  mild  degree  is  often  present  at  autopsy.  Lobar 
pneumonia  is  a  very  unusual  complication. 

Bronchopneumonia  is  found  at  the  autopsy  in  nearly  all  the  fatal 
cases.  The  development  of  the  disease  during  an  attack  of  scarlet 
fever  is  of  very  grave  importance. 

Otitis. — Otitis  is  a  frequent  and  dangerous  complication  of  scarlet 
fever.  If  all  cases,  the  mild,  the  moderately  severe,  and  severe,  are 
included,  it  will  be  found  in  over  lOper  cent. 

Albuminuria. — Early  in  the  average  case  albumin  will  be  found  in 
the  urine,  if  this  is  repeatedly  examined  and  with  sufficient  care.  This 
condition  does  not  constitute  nephritis,  however,  for  albumin  in  small 
amounts  will  be  found  in  most  diseases  of  toxic  origin  in  childhood. 

Nephritis. — Scarlatinal  nephritis  rarely  appears  before  the  third 
week  of  the  disease.  I  have  known  cases  to  develop  as  late  as  the 
twelfth  week  after  the  onset.  The  nephritis  is  of  the  glomerular  type, 
and  more  likely  to  occur  after  mild  infections.  The  first  sign  will 
usually  be  that  of  a  puffiness  under  the  eyes  and  about  the  ankles. 
The  urine  becomes  scanty  and  high  colored.  This  complication  will 
be  referred  to  again  on  p.  655. 

Arthritis. — Joint  complication  has  been  present  in  but  5  per  cent,  of 
my  cases.  The  arthritis  is  the  manifestation  of  a  local  infection. 
There  may  be  swelling  and  redness  of  two  or  more  of  the  joints.  The 
lesion  has  always  been  multiple;  I  have  never  known  one  joint  alone  to 
be  involved.  In  some  cases  pain  alone  will  be  present,  without  either 
of  the  above  symptoms.     A  fatal  case  of  pyemic  arthritis  was  seen  by 


SCARLET    FEVER    (sCARLATINa)  649 

me  in  consultation  with  the  late  Dr.  Mclnerny,  of  New  York.  The 
joints  at  the  knees,  ankles,  elbows,  and  wrists  suppurated.  This  child 
died. 

Mortality. — The  mortality  varies  greatly.  Different  epidemics  give 
a  different  mortality.  In  institution  epidemics  the  mortality  is  higher 
than  in  private  life.  In  the  New  York  Infant  Asylum,  during  my 
service,  the  mortality  in  children  under  six  years  of  age  was  20  per  cent. 
In  private  work  the  average  mortality  ranges  under  10  per  cent. 

Prophylaxis. — The  most  efficient  safeguard  is  a  normal  throat. 
The  presence  of  enlarged  tonsils  and  adenoids  doubtless  increases  the 
susceptibility  to  the  disease,  and  their  presence  adds  greatly  to  the 
dangers. 

Quarantine. — The  isolation  of  those  ill  with  contagious  diseases  is 
an  absolute  necessity  for  the  protection  of  others.  While  it  is  advis- 
able in  cases  of  scarlet  fever  to  remove  from  the  house  children  who 
have  not  had  the  disease,  and,  in  the  event  of  diphtheria,  all  children, 
regardless  of  previous  attacks,  such  removal  is  often  impossible.  It 
then  becomes  our  duty  to  establish  such  a  quarantine  as  will  be  effective 
in  preventing  the  transmission  of  the  disease.  In  order  to  do  this,  the 
child  and  the  attendant  must  not  come  in  contact  with  other  members 
of  the  family,  whether  children  or  adults.  If  the  residence  is  a  city  or 
a  country  house,  one  or  two  rooms  on  the  top  floor  should  be  selected 
for  the  patient,  the  room  from  which  he  was  removed  being  carefully 
cleaned  and  disinfected.  If  the  family  occupy  an  apartment,  an  effect- 
ive isolation  is  more  difficult,  but  is  by  no  means  impossible.  In  such 
circumstances  the  room  or  rooms  must  be  as  remote  as  possible  from 
the  other  living-rooms.  The  room  in  which  the  child  is  placed  should 
be  prepared  for  the  patient  according  to  the  instructions  laid  down  on 
p.  650.  Not  only  should  the  attendant  not  come  in  direct  contact  with 
other  members  of  the  family,  but  there  must  be  no  indirect  contact 
through  dishes,  feeding  utensils,  clothing,  or  bed-linen.  The  dishes, 
knives,  forks,  and  spoons  should  be  placed  in  boiling  water  and  in  this 
sent  to  the  kitchen.  The  clothing,  towels,  and  bed-linen  should  be 
placed  either  in  boiling  water  or  in  a  carbolic  solution — one  ounce  to 
two  gallons  of  water — before  sending  them  to  the  laundry.  Upon  their 
arrival  at  the  laundry  they  should  be  boiled  at  once.  A  chair  outside 
the  door  of  the  sick-room  may  be  used  as  a  receptacle  for  the  various 
articles  for  the  patient,  which  are  to  be  removed  only  when  the  person 
who  brought  them  is  at  a  safe  distance. 

Two  isolating  rooms  are  better  than  one,  and  if  there  can  be  a  con- 
necting bath-room,  it  is  much  more  agreeable  to  the  occupants.  If  two 
rooms  are  devoted  to  the  patient,  one  is  to  be  used  for  day  and  the 
other  for  night  occupancy,  the  unoccupied  room  being  freely  ventilated 
after  the  removal  of  the  child.  Observing  the  above  precautions  until 
the  child  is  well,  I  have  repeatedly  carried  through  to  successful  conva- 
lescence cases  of  diphtheria  and  scarlet  fever  while  other  unprotected 
children  have  remained  in  the  household  during  the  entire  illness  with- 
out taking  the  disease. 


650  THE    PRACTICE    OF    PEDIATRICS 

An  incident,  previously  referred  to,  which  well  demonstrates  the 
value  of  proper  quarantine,  occurred  at  the  New  York  Infant  Asylum, 
Mt.  Vernon,  New  York,  during  my  service  as  intern  in  that  institution. 
The  institution  was  built  on  the  cottage  plan,  two  wards  in  a  cottage. 
A  colored  child,  an  occupant  of  one  of  the  upper  wards,  was  discovered 
to  be  ill  with  scarlet  fever.  There  was  an  extensive  rash,  considerable 
swelling  of  the  cervical  glands,  and  the  whole  aspect  of  the  case  was 
that  of  scarlet  fever  at  its  height.  Through  the  negligence  of  an  orderly 
the  child  had  probably  been  ill  two  or  three  days  before  our  attention 
was  called  to  him ;  as  a  consequence,  30  other  children  of  the  ward  had 
been  exposed.  In  order  to  prevent  the  spread  of  the  disease  to  the 
other  400  children,  it  was  decided  to  quarantine  the  ward  with  its 
children  and  the  4  attendants.  This  was  done.  Twenty-six  children 
and  one  woman  attendant  developed  the  disease.  The  quarantine,  on 
the  plan  above  suggested,  was  continued  for  ten  weeks.  The  thirty  or 
more  children  on  the  ground  floor  of  the  cottage  remained  there  as  be- 
fore, but  no  other  case  developed  in  the  institution.  In  order  to  pre- 
vent the  spread  of  the  contagion,  there  was  no  personal  contact  with 
those  outside  of  the  ward,  except  on  thQ  part  of  the  physician  who 
visited  them  daily,  but  who  always  went  properly  protected.  All 
clothing  and  bed-linen  were  boiled  before  being  removed  from  the  ward. 
The  dishes  and  feeding  utensils  were  likewise  boiled  before  being  sent  to 
.  the  general  kitchen. 

If  such  isolation  is  possible  in  an  institution  among  the  careless  and 
more  or  less  ignorant,  it  certainly  should  be  equally  effective  among  the 
intelligent,  who  are  most  interested  in  preventing  the  spread  of  disease. 

When  the  quarantine  is  raised,  the  child  should  receive  a  bath  of 
hot  water  and  thorough  scrubbing  with  plenty  of  soap.  A  few  hours 
later  a  bath  of  bichlorid  1:3000  should  be  given.  If  the  hair  is  cut 
short  and  shampooed  with  green  soap,  followed  by  the  bichloride,  the 
disinfection  is  more  complete. 

Treatment. — The  patient  must  be  kept  in  bed  throughout  the  en- 
tire illness,  of  from  four  to  six  weeks  ;i.e.,  from  the  onset,  first  manifested 
by  sore  throat  and  fever,  until  the  desquamation  is  completed  (see 
Quarantine,  p.  649).  We  must  realize  at  the  outset  the  possibilities  due 
to  the  virulence  of  the  infection  and  the  complications.  The  death- 
rate  in  scarlet  fever  epidemics  varies  from  10  to  30  per  cent.  In  greater 
New  York  from  350  to  450  children  under  ten  years  of  age  die  from 
scarlet  fever  or  its  complications  every  year.  In  order  to  do  our  full 
duty  to  the  patient  we  must  place  him  in  the  best  possible  position  for 
successfully  combating  the  disease. 

The  Sick-room. — The  sick-room  should  be  as  large  as  it  is  possible 
for  the  family  to  supply.  It  is  desirable  that  it  be  well  hghted  by  two 
windows  which  will  make  free  ventilation  possible.  For  the  latter 
purpose,  the  window-board  (p.  138)  answers  well.  There  should  al- 
ways be  a  direct  communication  with  the  open  air,  except  when  the 
child  is  being  bathed  or  the  clothing  changed.  Light  and  the  free  cir- 
culation of  fresh  air  are  absolutely  necessary  for  the  proper  manage- 


SCARLET    FEVER    (sCARLATINA)  ,   651 

ment  of  a  severe  case  of  scarlet  fever.  If  possible,  two  rooms  should  be 
used — one  for  the  day,  the  other  for  the  night.  The  room  which  is  not 
occupied  should  have  the  window  or  windows  wide  open.  When 
nephritis,  endocarditis,  or  otitis  develops,  they  are  the  result  of  the 
scarlet  fever  poison  or  associated  infection,  and  not  due  to  the  fact  that 
a  window  was  left  open. 

Clothing. — The  child  requires  no  extra  jacket  or  wraps.  The  cus- 
tomary night-gown,  with  the  light  gauze  undershirt  and  the  usual 
bed-covering,  is  all  that  is  required. 

Urine  Examinations. — The  urine  should  be  examined  for  albumin 
every  day.  It  is  my  practice  to  have  the  family  get  a  few  test-tubes 
and  a  bottle  of  chemically  pure  nitric  acid.  When  the  busy  physician 
has  the  daily  specimen  sent  to  his  office  or  carries  it  home  himself,  it  is 
sometimes  forgotten,  misplaced,  or  lost.  During  convalescence,  when 
the  daily  visit  is  not  made,  the  nurse  or  some  intelligent  member  of  the 
family  may  be  instructed  to  make  the  test  and  report  if  trouble  is  dis- 
covered. Because  of  a  lack  of  these  precautions,  nephritis  may  easily 
be  overlooked  until  puffiness  about  the  eyes  and  edema  of  the  lower 
extremities  are  discovered  by  the  attendant  after  albumin  has  been 
present  in  the  urine  for  several  days. 

Diet. — In  the  bottle-fed  during  the  acute  febrile  stage  the  food 
strength  should  be  reduced  one-half  by  the  use  of  boiled  water.  If  the 
child  is  getting  eight  ounces  of  a  milk  mixture,  four  ounces  of  this  mix- 
ture should  be  given  with  four  ounces  of  water.  For  older  children,  the 
diet  should  be  considerably  restricted  not  only  during  the  acute  stage, 
but  during  the  entire  course  of  the  disease.  During  the  acute  febrile 
stage  diluted  milk,  gruels,  and  orange-juice  should  constitute  the 
diet.  To  a  child  from  two  to  four  years  of  age,  5  ounces  of  milk  with 
5  ounces  of  barley  gruel  No.  2  (see  formulary,  page  70)  may  be  given 
at  four-hour  intervals — 4  or  5  feedings  in  twenty-four  hours,  which 
make  an  acceptable  diet.  Variations  may  be  made  in  the  gruels  used. 
Wheat,  rice,  and  granum  may  all  be  brought  into  use,  made  as  suggested 
in  the  formulary  and  given  with  equal  parts  of  milk.  It  is  always  well, 
in  the  feeding  of  sick  children,  to  provide  for  some  variety  in  the  food, 
in  order  that  the  child  may  not  tire  of  it.  The  juice  of  one-half  an 
orange  may  be  given  twice  daily,  three  hours  after  the  milk  and  the 
gruel  feeding.  For  the  sake  of  variety  I  occasionally  allow  a  glass  of 
whey  or  kumyss,  or  a  glass  of  skimmed  milk  containing  ^4,  ounce  of 
limewater.  Toasted  bread,  zwieback,  or  plain  crackers,  dry  or  in  di- 
luted milk,  may  be  given  occasionally. 

Milk  Diet. — The  extensive  milk  diet  in  the  management  of  scarlet 
fever,  about  which  we  have  all  heard  and  still  hear  a  great  deal,  has  not 
been  so  successful  in  my  hands  as  has  the  foregoing.  My  observation 
has  been  that  the  exclusive  milk  diet  is  apt  to  produce  constipation, 
intestinal  indigestion,  coated  tongue,  loss  of  appetite — that,  in  fact, 
the  child  ''grows  stale"  on  the  milk,  which  is  to  be  our  dietetic  main- 
stay during  the  weeks  that  are  to  follow.  During  the  post-febrile 
period  slight  additions  should  be  made  to  the  diet  by  the  use  of  farina, 


652  THE  PRACTICE  OF  PEDIATRICS 

hominy,  wheatena,  and  the  hghter  cereals,  prepared  as  porridge  with 
a  sprinkhng  of  sugar  and  a  Httle  milk.  The  child's  customary  diet 
should  not  be  resumed  until  four  weeks  have  elapsed  from  the  com- 
miencement  of  the  attack.  If  the  case  has  been  a  severe  one,  showing 
marked  systemic  infection,  six  weeks  should  elapse  before  the  full  diet 
is  resumed. 

Bowel  Evacuation. — There  should  be  one  evacuation  of  the  bowels 
daily.  If  this  does  not  take  place,  a  soap-water  enema  should  be  given. 
If,  on  account  of  the  diet  and  the  recumbent  position,  there  is  a  tendency 
to  constipation,  a  glass  of  malted  milk — 6  teaspoonfuls  of  the  malted 
milk  to  8  ounces  of  water — as  a  part  of  the  evening  meal  will  be  of  ser- 
vice in  relieving  the  condition.  The  addition  of  one  teaspoonful  of 
cocoa  will  be  acceptable  when  the  taste  of  malted  milk  is  objectionable. 

Laxatives. — As  a  laxative  during  the  acute  febrile  stage,  citrate  of 
magnesia  is  very  satisfactory.  As  a  rule,  children  like  it,  and  to  those 
from  two  to  five  years  of  age  it  may  be  given  in  doses  of  from  2  to  4 
ounces.  In  case  it  is  not  well  taken,  from  one  to  two  teaspoonfuls  of 
the  aromatic  cascara  may  be  given. 

Specific  Medication. — There  is  no  specific  medical  treatment  for 
scarlet  fever.  Many  of  my  cases  have  passed  through  the  entire  illness 
without  the  use  of  any  other  measures  than  those  suggested  above. 

Serum  Treatment. — The  value  of  the  serum  treatment  has  been  by 
no  means  demonstrated,  and  its  use  is  not  advised.  The  preparation 
of  serum  and  its  use  before  we  know  the  nature  of  the  scarlet  fever 
poison  is,  to  say  the  least,  premature.  The  only  use  of  therapeutic 
measures,  so  far  as  we  know  at  the  present  time,  regardless  of  the  kind 
employed,  is  to  assist  the  organism  in  battling  with  the  disease. 

Nursing. — As  the  course  of  scarlet  fever  is  distinctly  cyclic  in  char- 
acter, much  can  be  done  in  the  most  severe  cases  to  prevent  complica- 
tions and  to  relieve  the  patient  of  his  temporary  burden.  Since  one  of 
the  most  important  offices  we  have  to  perform  is  to  keep  the  vital  force 
at  the  highest  possible  point,  we  must  do  everything  in  our  power  to 
preserve  the  natural  resistance  of  the  patient,  and  this  we  have  done 
in  no  small  degree  when  we  have  so  arranged  for  clothing,  diet,  fresh 
air,  bowel  evacuation,  sleep,  and  quiet  as  to  insure  the  child's  comfort 
and  well-being.  The  amount  of  vitality  wasted  by  an  uncomfortable, 
restless  child  in  twenty-four  hours  may  turn  the  case  from  a  successful 
to  a  fatal  issue. 

I  fully  believe  in  "spoiling"  a  sick  child.  If  a  child  is  more  at  ease 
with  the  mother,  the  mother's  place  is  with  the  child.  If  the  mother's 
presence  disturbs  the  child,  as  it  does  in  some  instances,  she  should  be 
kept  in  the  background.  If  it  is  apparent  that  the  nurse  selected  is  not 
to  the  child 's  liking,  or  not  adapted  to  the  case,  another  nurse  should  be 
secured.  I  have  been  obliged  repeatedly  to  take  my  best  nurses  from 
children  gravely  ill,  because  the  patients  were  irritable  and  unhappy  in 
their  presence. 

Quiet. — Quiet  is  most  necessary.  One  person  only  should  be 
allowed  in  the  sick-room  with  a  child  very  ill.     A  second  person  is  of  no 


SCARLET    FEVER    (sCARLATINA)  653 

service,  and  if  admitted,  vitiates  good  air.  Moreover,  it  is  not  to  be 
expected  that  two  persons  of  the  "female  persuasion"  in  the  same  room 
will  not  talk! 

Control  of  Fever. — I  find  it  a  safe  rule  not  to  allow  the  temperature 
to  go  much  above  104°F.  A  higher  temperature  than  this  necessitates 
an  overworked  heart.  For  the  purpose  of  controlling  the  temperature, 
a  fifteen-minute  sponging  every  hour  with  water  at  90°F.  may  be  tried. 

Packs. — If  sponging  does  not  answer,  the  pack  (p.  777)  should  be 
brought  into  use.  The  mere  existence  of  a  rash  is  no  contraindication 
to  the  application  of  moderate  cold  to  the  skin.  The  pack  may  be  used 
in  scarlet  fever,  just  as  in  pneumonia  or  typoid  fever.  The  fear  that 
the  disease  may  "strike  in"  and  kill  the  patient  is  one  of  the  many 
inexplicable  ideas  of  the  laity  with  no  foundation  in  fact.  The  child 
is  placed  in  the  pack  at  95°F.  It  will  rarely  be  necessary  to  reduce  the 
temperature  of  the  pack  below  80°F.  If  the  case  is  of  the  fulminating 
type,  with  persistent  high  temperature,  the  pack  may  gradually  be 
reduced  to  a  temperature  of  70°F.  In  thus  reducing  the  temperature 
the  towel  is  not  to  be  removed  from  the  patient.  He  is  turned  from  side 
to  side  and  the  towel  moistened  with  water  at  the  desired  temperature. 
Time  and  again  I  have  seen  a  child  who  was  tossing  about  the  bed, 
delirious  and  sleepless,  fall  into  a  quiet  sleep  when  placed  in  a  pack. 
With  a  reduction  of  the  temperature  there  is  a  corresponding  diminu- 
tion in  the  pulse-beats  of  from  20  to  30  a  minute.  When  we  think 
what  a  saving  this  is  to  the  work  of  the  heart,  the  benefit  is  most 
apparent. 

Tub-baths. — The  full  tub-bath  at  a  temperature  of  95°F.  for  ten 
minutes  at  the  commencement  of  a  case  in  which  there  is  a  great  deal 
of  restlessness  and  irritability  will  often  act  most  satisfactorily  in  quiet- 
ing the  patient.  Tub-bathing,  however,  requires  a  great  deal  of  handl- 
ing of  the  patient,  and  in  the  cases  in  which  there  is  persistent  high  tem- 
perature, and  in  those  in  which  it  mounts  up  suddenly  after  the  bath, 
the  pack  is  far  the  more  satisfactory.  In  some  cases  with  intense  pros- 
tration and  high  fever  and  cold  extremities,  the  warm  bath — 105°F. 
to  110°F. — for  ten  minutes  will  have  a  most  satisfactory  effect.  The 
fever  is  reduced,  the  child  is  quieted,  and  the  heart  action  improved. 

Oil  Inunction. — The  itching  and  burning  of  the  skin  in  scarlet  fever 
is  most  distressing.  This  is  relieved  to  a  considerable  degree  by  the 
pack.  The  child 's  comfort  wiU  also  be  greatly  enhanced  by  an  inunc- 
tion twice  daily  of  cold-cream  or  liquid  albolene-.  Vaselin  or  olive  oil 
may  be  used,  but  they  are  much  less  satisfactory.  Vaselin  will  act  as  an 
irritant  to  some  sensitive  skins. 

During  the  period  of  desquamation  the  oily  applications  largely 
prevent  a  free  distribution  of  the  scales. 

Stimulants. — If  during  sleep  the  pulse  is  over  150  a  minute,  and  the 
cardiac  first  sound  is  weakened,  a  heart  stimulant  is  necessary.  To  a 
child  one  year  of  age  one  drop  of  tincture  of  strophanthus  at  two-hour 
intervals,  or  an  equal  amount  of  the  tincture  of  digitalis,  should  be 
given.     On  account  of  its  being  well  borne  by  the  stomach,  the  tincture 


654  THE  PRACTICE  OF  PEDIATRICS 

of  strophanthus  is  always  to  be  preferred.  Strychnin  is  a  remedy  of 
considerable  value  as  a  heart  stimulant.  When  the  pulse  is  soft  and 
the  heart  action  shows  a  tendency  to  irregularity,  3^^oo  grain  may  be 
given  every  two  to  four  hours  to  a  child  from  one  to  three  years  of  age, 
and  Hso  grain  to  a  child  from  three  to  six  years  of  age,  at  intervals 
of  from  two  to  four  hours.  Alcohol  should  be  used  only  in  the  septic, 
asthenic  cases  when  other  means  of  stimulation  have  failed.  In  such 
instances  it-  should  be  used  freely.  In  a  few  cases  I  have  used  it  in 
very  large  quantities  with  striking  benefit.  One-half  dram  of  whisky, 
at  first  given  every  two  hours,  may  be  increased  gradually  until  its 
beneficial  effects  are  noticed  on  the  heart  action.  It  is  astonishing 
how  much  alcohol  may  be  given,  in  a  profoundly  septic  case,  without 
the  slightest  effect,  except  an  improvement  in  the  heart  action,  and  a 
corresponding  improvement  in  the  child's  general  condition. 

Care  of  the  Throat  and  Nose. — The  throat  and  nose  demand  our 
attention  during  the  acute  stage.  For  the  nose  toilet  in  older  children, 
a  solution  of  menthol  and  liquid  albolene  may  be  used  by  means  of  an 
atomizer,  and  in  the  very  young  by  instillation  with  a  medicine-drop- 
per. Forcible  syringing  of  the  nose  in  a  young  child  is  not  a  safe  pro- 
cedure even  in  the  most  skilled  hands.  Local  treatment  of  the  throat 
depends  entirely  upon  its  condition.  If  the  mucous  membrane  is 
swollen,  edematous,  and  covered  with  a  glairy,  mucopurulent  secre- 
tion, if  there  is  a  psue  do  membrane,  or  if  there  is  much  pain  or  discomfort 
upon  swallowing,  local  treatment  is  required.  The  child  should  be 
made  to  gargle,  if  old  enough;  or,  far  better,  the  throat  may  be  irri- 
gated with  hot  saline  solution  at  120°F.  This  is  done  in  the  manner 
described  on  p.  278.  Force  will  be  required  with  the  very  young.  In 
older  children  the  relief  from  pain  that  is  experienced  from  free  irriga- 
tion is  so  great  that  usually  the  child  takes  the  tube  in  his  mouth 
gladly  for  the  future  irrigations.  The  use  of  antiseptic  gargles  and 
washes  has  not  seemed  to  me  to  possess  any  value  other  than  that  of 
cleanliness,  and  free  douching  acomplishes  this  in  a  far  more  satisfactory 
manner. 

Treatment  of  Complications. — Cervical  Adenitis. — Cervical  adenitis 
is  a  very  frequent  complication  of  scarlet  fever,  and  when  suppuration 
occurs,  it  is  most  troublesome.  On  the  first  appearance  of  a  swollen 
gland,  a  cold  compress  should  be  applied  and  then  kept  on  constantly  day 
and  night,  until  the  swelling  has  materially  subsided. 

The  temperature  of  the  water  should  be  from  50°  to  60°F.  The 
compresses  should  be  changed  every  thirty  minutes  during  the  day  and 
at  least  every  two  hours  during  the  night.  Several  thicknesses  of  old 
linen,  such  as  are  furnished  by  a  table  napkin,  answer  well  as  a 
medium  for  applying  the  cold.  The  material  used  should  be  cut  of 
sufficient  length  to  extend  from  ear  to  ear  under  the  jaw.  In  order 
that  the  moisture  may  be  retained,  oiled  silk  or  rubber  tissue  may 
be  placed  over  the  dressing,  and  over  all  a  thin  gauze  bandage,  which 
is  pinned  together  on  top  of  the  head. 

Otitis. — Otitis  is  a  complication  in  10  to  30  per  cent,  of  the  cases  of 


SCARLET    FEVER    (sCARLATINa)  655 

scarlet  fever.  In  view  of  the  grave  possibilities  of  mastoid  involvement, 
sinus  thrombosis,  and  jugular  bulb  infection,  the  presence  of  pus  in  the 
middle  ear  should  be  promptly  detected,  and  the  pus  evacuated  by  a 
free  incision  of  the  drum  membrane.  The  presence  of  middle-ear 
infection  may  be  suggested  by  a  pain  or  a  sensation  of  fullness  in  those 
old  enough  to  locate  it.  In  infants,  restlessness,  sleeplessness,  or 
tenderness  on  manipulation  in  cleansing  the  ears  may  be  the  only  ob- 
jective sign  of  the  trouble.  In  the  majority  of  my  cases  of  otitis,  none 
of  the  above  signs  of  pain  and  discomfort  were  present.  The  ear  in- 
volvement was  suggested  because  of  a  continued  elevation  of  tempera- 
ture which  could  not  otherwise  be  accounted  for.  A  persistent  elevation 
of  the  temperature  of  unknown  origin  following  scarlet  fever  is 
sufficient  occasion  for  examination  of  the  ears  by  an  expert  in  otoscopy. 
As  a  routine  measure  during  the  fever,  the  condition  of  the  drum  mem- 
brane should  be  noted  at  least  every  second  day. 

As  stated  above,  otitis  develops  in  from  10  to  30  per  cent,  of  the 
cases,  depending  somewhat  upon  the  character  of  the  epidemic,  but 
more  upon  the  age  of  the  patient.  The  younger  the  child,  the  greater 
the  danger  of  ear  involvement.  Many  cases  of  deafness  which  we  meet 
have  had  their  origin  in  an  attack  of  scarlet  fever,  and  are  due  to  some- 
body's ignorance  or  neglect.  Among  185  cases  of  scarlatinal  otitis 
reported  by  Bezold  and  quoted  by  Holt,  in  30  there  was  entire  destruc- 
tion of  the  membrana  tympani;  in  59,  the  perforation  comprised  two- 
thirds  or  more  of  the  membrane;  in  13,  there  were  small  perforations; 
in  44,  there  were  granulations  or  polypi;  in  15  there  was  total  loss  of 
hearing  on  one  side,  and  in  6  of  the  cases  upon  both  sides;  in  77,  the 
hearing  distance  for  low  voice  was  less  than  twenty  feet.  May,  of  New 
York,  has  collected  statistics  of  5613  deaf-mutes,  of  whom  572  owed 
their  condition  to  otitis  following  scarlet  fever.  When  we  consider 
how  many  cases  of  permanent  ear  defects  have  occurred  and  do  occur 
every  year  as  a  result  of  carelessness  or  lack  of  even  an  elementary 
knowledge  of  aural  diagnosis,  we  do  not  feel  inclined  to  congratulate  the 
members  of  the  medical  profession  on  their  ability  to  complete  their 
cases.  The  bacteriology  of  scarlatinal  otitis  is  the  same  as  in  suppura- 
tive otitis  developing  with  or  following  any  other  infectious  disease, 
except  that  there  is  a  greater  tendency  to  severity  because  of  the 
liability  to  streptococcus  infection.  Prompt  rehef  demands  prompt 
recognition  of  the  condition  of  the  drum  membrane,  with  evacuation 
of  the  pus  and  suitable  after-treatment.  (See  Acute  Suppurative 
Otitis,  p.  604.)  This  will  not  be  possible  if  the  practitioner  does  not 
examine  the  ears  or  is  not  sufficiently  expert  to  recognize  a  diseased 
condition  when  he  sees  it. 

Cardiac  Involvement. — Heart  complications  are  not  particularly 
frequent  in  scarlet  fever.  Nevertheless  the  heart  should  be  examined 
daily.  In  my  own  observations,  they  have  been  present  in  about  2  per 
cent  of  the  cases.. 

Nephritis. — Early  in  the  cases  of  severe  infection  there  will  often 
be  discovered  a  transient  albuminuria  with  a  few  hvaline  casts.     There 


656  THE    PRACTICE    OF    PEDIATRICS 

may  be  slight  suppression  of  the  urine.  In  but  one  of  my  cases  was 
there  complete  anuria  at  this  stage  of  the  disease.  Within  thirty-six 
hours,  however,  after  the  first  sign  of  the  disease  in  this  case,  the 
kidneys  ceased  to  act,  and  the  child  died  on  the  third  day,  from  the 
acute  diffuse  nephritis.  The  condition-  of  the  kidney  giving  rise  to 
albuminuria  is  best  relieved  through  attention  to  the  skin  function  by 
the  use  of  a  bath  at  a  temperature  of  105°F.  every  six  or  eight  hours. 
The  child  may  remain  in  the  bath  for  ten  minutes,  during  which  time 
the  skin  should  be  vigorously  rubbed  with  the  bare  hand.  The  tincture 
of  aconite  in  doses  of  one  drop,  with  five  drops  of  sweet  spirits  of  niter 
for  a  child  eighteen  months  of  age,  will  usually  produce  a  satisfactory 
skin  action. 

What  is  known  as  scarlatinal  nephritis  rarely  appears  before  the 
third  week  of  the  disease.  I  have  known  cases  to  occur  as  late  as  the 
sixth  week.  The  management  of  this  complication  will  be  found  on 
page  445. 

Arthritis  as  a  complication  of  scarlet  fever  is  seen  in  only  a  few  of 
the  cases — about  3  per  cent.  There  may  be  swelling  or  redness  of  the 
parts,  or  both  these  symptoms  may  be  absent.  Whether  or  not  the 
swelling  is  present,  the  joints  are  very  painful  on  manipulation.  Af- 
fected joints  should  be  wrapped  in  old  linen,  saturated  with  lead  and 
opium  solution,  and  the  dressing  renewed  every  six  hours.  The  follow- 
ing lotion  has  answered  well  in  a  few  cases: 

I^     Mentholis Sjj 

Tincturae  opii 3iv 

Spiritus  vini  recti q.  s.  ad  5vj 

Soft  linen  is  moistened  with  the  lotion,  wrapped  about  the  parts, 
and  covered  with  oiled  silk  or  rubber  tissue.  The  part  affected  is  then 
wrapped  in  flannel  or  cotton- wool.  The  lotion  may  be  freshly  applied 
at  intervals  of  from  four  to  six  hours.  The  only  objection  to  its  use 
is  the  odor  of  the  menthol. 

Internally,  to  a  child  four  years  of  age,  aspirin  may  be  given  in  doses 
of  five  grains,  with  ten  grains  of  the  bicarbonate  of  soda  at  four-hour  in- 
tervals, four  doses  being  given  in  the  twenty-four  hours.  Salicylate 
of  soda  may  be  used  in  small  doses;  but,  as  this  may  be  badly  borne  by 
the  stomach,  aspirin  is  preferable. 

Surgical  Scarlet  Fever. — This  type  of  scarlet  fever  is  described 
in  the  text-books;  a  few  writers  strenuously  maintain  its  existence, 
while  others  doubt  it.  An  inoculation  of  the  disease  is  supposed  to 
take  place  through  an  abrasion  or  wound.  I  have  never  seen  a  case 
of  true  scarlet  fever  acquired  in  such  a  manner.  I  have  seen  surgical 
cases,  however,  develop  a  septic  rash  that  could  not  be  differentiated 
from  the  scarlet  fever  rash.  In  such  patients  the  skin  will  desquamate 
on  the  body  generally,  but  not  on  the  hands  and  feet.  There  is  no 
angina.  Further,  I  have  never  known  a  case  of  this  nature  to  transmit 
the  disease  to  others. 


TYPHOID  FEVER  657 


TYPHOID  FEVER 


Typhoid  fever  is  not  a  disease  common  to  infants  or  very  young 
children.  Persons  of  any  age  may  acquire  the  disease.  It  has  been 
estabhshed  that  the  fetus  may  be  infected  by  the  mother.  Different 
observers  have  proved  that  bacilh  in  the  fetal  organs  and  blood  have 
reacted  to  the  Widal  test.  Numerous  cases  are  reported  as  occurring 
during  the  first  months  of  life,  but  the  fact  that  these  cases  are  reported 
singly,  and  that  such  reports  are  commented  upon  and  quoted  by  other 
writers,  emphasizes  the  statement  that  typhoid  in  the  very  young  is 
extremely  rare.  In  a  large  hospital  and  private  experience,  covering 
many  thousands  of  cases  of  acute  illness  in  children,  during  a  period  of 
nearly  twenty-five  years,  I  have  seen  but  four  cases  of  proved  typhoid 
in  children  under  two  years  of  age.  The  youngest  was  eight  months 
old,  and  another  ten  months  old. 

Bacteriology. — Bacillus  typhosus  was  described  by  Eberth  in  1880 
and  cultivated  by  Gaffky  in  1884.  It  is  short,  it  does  not  retain  Gram 's 
stain,  and  grows  readily  upon  all  ordinary  laboratory  media.  The 
characteristic  features  of  the  organism  are  its  viability  and  its  inabihty 
to  produce  gas  in  any  sugar  medium.  The  Bacillus  typhosus  enters  the 
human  body  through  the  gastro-intestinal  tract,  usually  by  means 
of  polluted  water,  which,  in  turn,  may  contaminate  milk,  vegetables 
and  oysters.  During  the  course  of  an  attack  of  typhoid  fever  Bacillus 
typhosus  may  be  cultured  from  the  blood,  rose-spots,  feces,  the  urine, 
and  exceptionally  from  the  sputum.  The  bacilH  are  found  in  the 
blood  in  practically  all  cases  of  typhoid  fever,  most  frequently  during 
the  first  week,  less  frequently  in  each  succeeding  week.  In  the  feces 
the  bacilli  do  not,  as  a  rule,  appear  until  the  second  week,  when 
ulceration  has  begun;  they  remain  present  until  convalescence  is 
established.  The  urine  rarely  contains  typhoid  bacilli  before  the  end 
of  the  second  week  of  the  disease,  when  they  are  present  in  about 
25  per  cent,  of  all  cases.  The  urine  may  continue  to  show  the  bacilli 
for  weeks  or  months  after  convalescence.  In  the  gall-bladder  the 
bacilli  have  been  found  years  after  an  attack  of  typhoid  fever. 

Bacillus  typhosus  is  found  in  pus  from  complicating,  suppurating 
lesions  in  typhoid  fever,  such  as  periostitis,  osteomyelitis,  synovitis, 
meningitis,  peritonitis,  and  abscesses. 

Typhoid  carriers  are  estimated  by  Russell  to  develop  from  about 
3  per  cent,  of  all  typhoid-fever  patients.  These  persons  may  excrete 
the  bacilh  with  the  urine  or  feces  for  many  years  after  an  attack  of  the 
disease,  and  are,  therefore,  a  menace  to  those  about  them. 

Immune  bodies  develop  and  circulate  in  the  blood  of  the  patient 
with  typhoid  fever.  One  kind  of  immune  body  is  the  agglutinin, 
whose^  presence  is  demonstrable  by  the  Gruber- Widal  reaction.  This 
agglutination  of  typhoid  bacilli  by  the  diluted  serum  of  a  typhoid  fever 
patient  is  not  usually  apparent  until  the  second  week  of  the  disease, 
3.nd  may  be  delayed  until  the  seventh  week.  The  reaction  is  present, 
42 


658  THE  PRACTICE  OF  PEDIATRICS 

however,  some  time  during  the  attack  in  95  per  cent,  of  all  cases  of 
typhoid  fever,  and  is,  therefore,  a  diagnostic  aid  of  value. 

Pathology. — The  lesions  produced  by  typhoid  are  usually  much 
less  severe  in  children  than  in  adults.  Autopsies  upon  youthful  sub- 
jects have  at  times  revealed  no  intestinal  lesions  sufSciently  severe  to 
warrant  the  diagnosis.  In  nearly  all  cases,  however,  the  small  intes- 
tine is  the  seat  of  a  catarrhal  process,  and  although  there  may  be  no 
actual  ulceration,  the  solitary  follicles  and  Peyer's  patches  are  reddened 
and  swollen.  The  spleen  is  almost  always  enlarged.  Doubtful  find- 
ings may  be  substantiated  by  cultures  from  the  blood  and  intestinal 
contents. 

The  details  of  the  disease  process  have  been  well  explained  in  the 
following  paragraph  from  the  work  in  pathology  by  Adami  and 
Nicholls.*  ''According  to  Mallory,  the  essential  feature  of  typhoid  is  a 
proliferation  of  the  endothehal  cells  throughout  the  body,  a  change 
which  he  thinks  is  due  to  a  diffusible  toxin  derived  from  the  bacilli. 
The  lesion  in  question  is  found  in  Peyer's  patches,  mesenteric  glands, 
liver,  and  bone-marrow,  as  well  as  in  the  lymphatics  and  blood  capil- 
laries, but  is  proportionately  more  intense  the  nearer  to  the  point  at 
which  the  infecting  agent  gained  entrance.  The  endothehal  plates 
attached  to  the  fibrous  meshwork  of  capillaries  proliferate,  become 
fused  into  plasmodial  masses  or  giant-cells,  and  act  as  phagocytes. 
They  ingest  the  bacteria  and  slowly  eat  up  the  lymphoid  cells,  which 
thus  gradually  disappear.  A  few  leukocytes  are  to  be  seen  in  the 
follicles,  and  within  the  crypts  of  Lieberkiihn,  but  are  not  an  important 
feature.  Owing  to  the  massing  of  these  endothelial  cells  within  the 
capillaries  and  the  consequent  obstruction  to  the  blood-supply,  the 
parts  deprived  of  their  nutrition  undergo  necrosis.  The  focal  necroses 
in  the  hver  and  spleen  are  to  be  explained  in  the  same  way." 

Transmission. — Transmission  may  take  place  by  different  carriers, 
the  principal  ones  being  infected  water,  milk,  uncooked  vegetables,  and 
shell-fish.     That  the  disease  is  usually  water-borne  is  admitted  by  all. 

Anti-typhoid  Vaccination. — The  prophylactic  value  of  anti-typhoid 
vaccine  has  been  abundantly  established  in  both  civilian  and  army 
practice.  For  an  average  child  ten  years  of  age  one-half  the  adult  dose 
should  be  given.  Thus  if  500  million  is  given  for  the  first  dose,  1000 
million  for  two  subsequent  doses  at  intervals  of  ten  days,  a  total 
dosage  for  a  child  of  ten  years  would  be  1250  million. 

Reaction. — A  reaction  manifested  by  slight  fever  and  muscle  sore- 
ness and  fatigue  occurs  in  a  small  percentage  of  cases.  The  local  re- 
action is  slight,  there  may  be  pain,  tenderness  and  a  localized  infiltrated 
area.  The  neighboring  lymph-glands  may  show  temporary  enlarge- 
ment and  be  sensitive  to  touch.  This  condition  need  cause  no 
anxiety. 

Symptoms. — I  cannot  agree  with  those  writers  who  describe  urgent 
symptoms  early  in  a  case  of  typhoid. 

The  early  manifestations  in  a  great  majority  of  cases  consist  in 
*  Adami  and  Nicholls:  Principles  of  Pathology,  1909,  vol.  ii,  p.  439. 


TYPHOID    FEVER  659 

moderate  fever,  becoming  a  little  higher  each  day,  apathy,  and  drowsi- 
ness.    The  tongue  is  coated  and  there  is  loss  of  appetite. 

In  children  systemic  poisoning  from  intestinal  sources  appears  to 
have  some  selective  action  on  the  nervous  system;  thus,  disturbed  di- 
gestion, whether  acute  or  chronic,  is  productive  of  dreams  and  night- 
terrors.  Gastro-intestinal  disturbances,  more  than  any  other  factor, 
are  productive  of  convulsions.  In  typhoid  fever  the  central  nervous 
system,  similarly,  is  affected.  The  child  is  dull  and  apathetic.  So  in- 
definite are  the  signs  that  a  diagnosis  is  impossible  for  days,  and  often 
it  is  just  this  feature  of  absence  of  diagnostic  signs  that  arouses  a  sus- 
picion of  typhoid  fever.  Now  and  then  a  case  is  seen  with  stormy 
onset,  high  fever,  delirium,  and  rapid  pulse.  In  such  cases  there  is 
usually  an  associated  infection,  such  as  an  acute  intestinal  infection 
or  one  due  to  the  pneumococcus. 

Nervous  Symptoms. — In  mild  cases  the  nervous  manifestations  may 
be  slight  or  altogether  lacking,  or  there  may  be  apathy,  drowsiness, 
stupor,  and  delirium.  The  temperature  range  and  the  nervous  mani- 
festations appear  to  bear  little  relation  to  each  other;  thus,  with  a  low 
temperature  range  there  may  be  pronounced  stupor  and  delirium,  sug- 
gesting the  possibility  of  meningitis. 

The  Pulse. — The  pulse-rate  is  a  most  characteristic  sign.  It  is  com- 
paratively slow,  decidedly  out  of  relation  to  the  temperature  range — 
slower  than  in  any  other  illness  excepting  meningitis.  The  pulse  shows 
no  irregularity  in  force  or  rhythm.  I  have  seen  the  pulse  at  110  with  a 
temperature  of  104°F.     This,  in  itself,  is  a  most  suggestive  sign. 

The  Spleen. — The  spleen  is  usually  enlarged,  the  enlargement  cor- 
responding with  the  severity  of  the  attack.  The  organ  is  usually 
palpable  some  time  during  the  second  week,  but  in  mild  cases  may 
never  appear  below  the  free  border  of  the  rib. 

Gastro-intestinal  Symptoms. — Tympanites  is  the  rule ;  this  condition 
may  be  extreme  or  of  mild  degree,  or  it  may  not  exist.  With  suitable 
feeding,  this  feature  may  be  largely  eliminated. 

Either  diarrhea  or  constipation  may  be  present;  here  also  the  feed- 
ing of  the  patient  plays  an  important  part.  Patients  who  are  fed  with 
large  quantities  of  milk  will  often  have  diarrhea  or  constipation,  or  the 
two  conditions  alternating,  along  with  abdominal  distention,  high 
fever,  and  greater  toxicity. 

Rose  Spots. — Rose  spots  may  be  absent,  few  in  number,  or  scattered 
over  the  skin  surface.  They  appear  most  often  on  the  abdomen;  but 
frequently  also  on  the  chest  and  back. 

Duration  of  Immunity  Conveyed. — According  to  the  best  observers 
immunity  continues  from  2  to  2)-^  years,  at  the  end  of  which  time  a 
re-inoculation  should  be  undertaken. 

Advisability  of  Innoculating  Children. — Children  who  remain  at 
home  under  careful  supervision  will  not  require  inoculation,  as  the 
incidence  of  typhoid  under  such  conditions  is  very  small.  Those  who 
travel  about,  particularly  in  summer,  going  by  train  or  boat,  hving  in 
hotels  and  boarding  houses,  are  constantly  exposed  to  the  possibilities  of 


660  THE    PRACTICE    OF    PEDIATRICS 

typhoid  infection.     Such   children  should  have  the  value  of  anti- 
typhoid vaccination. 

Temperature. — The  temperature  range  is  variable.  In  the  case  of  a 
boy  of  ten  years,  who  showed  a  positive  reaction,  the  temperature 
lasted  two  weeks  but  was  never  above  100.5°F.  by  mouth.  The  usual 
range  in  my  cases  has  been  101°  to  103°F.,  perhaps  occasionally  reach- 
ing 104°F.  It  has  been  extremely  rare  for  the  temperature  to  con- 
tinue after  the  eighteenth  day.  My  shortest  temperature  record  was 
that  of  a  ten-year-old  girl,  the  duration  of  her  fever  being  ten  days.  In 
typhoid  a  very  high  temperature  is  not  always  a  bad  prognostic  sign. 

Illustrative  Case. — In  a  girl  whom  I  saw  in  consultation  with  Dr.  Staub,  of 
Stamford,  Conn.,  there  was  a  temperature  range  for  eleven  days  of  104°  to  106°F., 
and  from  101°  to  104°  for  ten  days  longer,  the  entire  duration  of  temperature  being 
thirty-six  days.     During  the  illness  the  child  did  not  appear  to  be  very  ill. 

This  observation  has  been  repeated  in  other  cases. 

Intestinal  Hemorrhage. — Intestinal  hemorrhage  is  very  rare  in 
children.     Perforation  I  have  never  known. 

Complications. — The  complications  of  typhoid  in  children  have 
been  exceedingly  rare  in  my  experience  with  the  disease,  and  fatalities 
have  been  of  most  unusual  occurrence. 

The  fact  that  typhoid  fever  bacilli  may  be  cultivated  from  the  blood 
and  urine  implies  that  infection  of  various  organs  in  the  body  may  and 
does  occur;  thus  the  disease  may  cause pyeli tits,  peritonitis,  meningitis, 
osteomyelitis,  synovitis,  otitis,  and  abscesses.  When  broncho- 
pneumonia occurs  with  typhoid  fever,  it  is  usually  a  terminal  infection. 

Suspicious  Diagnostic  Signs. — Apathy,  drowsiness,  a  gradually  ris- 
ing temperature-curve,  with  diarrhea  and  perhaps  tympanites. 

Diagnostic  Signs. — Positive  Widal  reaction;  elevation  of  tempera- 
ture, and  pulse  slow  in  comparison  to  the  temperature ;  involvement  of 
the  central  nervous  system,  drowsiness,  stupor,  delirium,  enlarged 
spleen,  and  rose  spots. 

The  Widal  test  may  be  corroborated  by  culturing  the  blood  and 
urine  and  by  examination  of  the  feces. 

Differential  Diagnosis. — Any  continued  fever  of  unknown  origin, 
until  very  recent  years,  would  have  been  called  typhoid  or  malaria. 
It  was  only  a  few  years  ago  that  some  of  our  best  clinicians  in  this 
country  and  in  other  lands  diagnosed  as  typhoid  every  continued 
fever  which  did  not  respond  to  quinin,  and  for  which  no  adequate  cause 
could  be  discovered. 

With  the  exact  means  of  diagnosis  which  are  at  our  disposal  at  the 
present  time  there  is  no  occasion  for  failure  to  differentiate  malaria, 
typhoid,  and  the  conditions  with  temperatures  due  to  occult  pus. 

The  nervous  phenomena  of  typhoid,  when  particularly  pronounced, 
may,  upon  inspection  alone,  closely  simulate  those  of  meningitis.  In 
typhoid  the  respirations,  if  slow,  are  regular  and  of  even  depth;  the 
pulse  is  slow  and  regular.  In  meningitis  irregularity  or  some  atypical 
condition  characterizes  the  pulse;  it  may  be  very  rapid, — 180  to  200, — 


TYPHOID    FEVER  661 

with  a  temperature  of  101°  or  102°F.  The  spleen  is  not  enlarged  in 
meningitis,  nor  are  rose  spQts  present. 

Acute  miliary  tuberculosis  may  simulate  typhoid.  In  tuberculosis 
of  this  form  there  is  absence  of  all  signs  excepting  the  fever,  which  is 
usually  very  high  in  children  of  the  typhoid  age.  The  eruption,  and 
the  mental  dulness  of  typhoid,  are  not  seen  in  acute  miliary  tubercu- 
losis.    An  enlargement  of  the  spleen  may  be  present  in  both  diseases. 

Mortality. — Many  of  the  mortality  tables  are  valueless.  Statistics 
of  cases  and  diagnoses  antedating  the  Gruber-Widal  reaction  and  the 
discovery  of  the  bacillus  in  the  blood,  urine,  and  feces  are  inaccurate. 
Thus,  in  one  series,  in  infants  under  one  year  of  age,  we  find  the  mor- 
tality given  as  50  per  cent. 

The  mortality  in  private  cases  treated  in  homes  or  private  institu- 
tions ranges  from  2  to  3  per  cent.  In  cases  treated  in  hospital  wards 
or  in  institutional  homes  it  ranges  from  8  to  10  per  cent. 

In  95  hospital  cases  Koplik  lost  9  patients — a  mortality  of  9.4  per 
cent.     Henoch,  in  375  cases,  had  a  mortality  of  14  per  cent. 

Treatment. — While  usually  the  disease  runs  a  shorter  course  in  the 
child  than  in  the  adult,  an  attack  means,  at  the  least,  several  days  of 
illness,  and  it  may  means  from  three  to  six  weeks.  For  this  reason  it 
is  best  to  establish  a  sick-room  regime,  under  which  must  be  particularly 
considered  the  feeding,  the  bathing,  the  airing  of  the  room,  and  the 
maintenance  of  absolute  quiet  for  the  patient.  The  bed-linen  should 
be  changed  every  day,  and  if  the  patient  becomes  very  ill,  but  one  at- 
tendant at  a  time  should  be  in  the  sick-room. 

Bathing. — The  typhoid  patient  should  be  sponged  twice  a  day,  an 
ordinary  cleansing  bath  being  given.  During  the  bath,  it  is  not  neces- 
sary to  uncover  the  body.  Parts  may  be  bathed  and  dried,  after 
which  other  parts  may  be  given  attention. 

Mouth  Toilet. — Careful  mouth  toilet  should  be  observed.  Gingivi- 
tis and  ulcerative  stomatitis,  with  secondary  involvement  of  the  cervi- 
cal lymph-nodes,  are  not  infrequent  compUcations  of  these  cases. 

Care  of  the  Discharges. — The  discharges  from  both  bladder  and  in- 
testine should  be  received  in  vessels  containing  a  1  :1000  solution  of 
bichlorid  of  mercury.  Carbolic  acid  should  not  be  used.  The  necessity 
for  the  attendants  to  wash  their  hands  with  soap  and  water  after 
attending  to  the  patient  should  be  made  very  plain.  Attendants  should 
also  be  advised  as  to  the  proper  disposal  of  the  discharges.  In  children 
of  tender  age  who  still  require  the  napkin  it  is  best  to  dispense  with  the 
usual  article  and  use  cheese-cloth  instead,  several  thicknesses  of  which 
may  be  made  of  the  required  shape  and  burned  when  soiled. 

The  Feeding  of  Typhoid  Fever  Cases. — Contrary  to  the  general  prac- 
tice, I  give  little  or  no  milk  in  typhoid  cases.  Early  in  my  professional 
work"  I  gave  milk,  which  I  had  been  taught  afforded  the  only  diet  for 
the  typhoid  patient.  I  soon  discovered  that  the  less  the  milk  given,  the 
less  was  the  tympanites.  I  found  that  without  milk  the  temperature 
course  was  lower,  that  there  was  less  tendency  to  delirium,  that 
the  duration  of  the  case  was  shorter  and,  as  a  whole,  less  severe.     In 


662  THE    PRACTICE    OF    PEDIATRICS 

fact,  my  observations  bear  out  the  teaching  of  Seibert,  of  New  York, 
who  was  the  first  to  advocate  the  non-milk  diet  in  typhoid  fever. 

The  diet  which  I  now  use  consists  largely  of  gruels,  made  from 
cracked  wheat,  barley,  rice,  oatmeal,  or  any  of  the  uncooked  cereals. 
I  order  one  ounce  of  the  cereal  boiled  for  three  hours  in  one  pint  of  water. 
At  the  completion  of  the  boiling,  boiled  water  is  added  to  make  the 
quantity''  of  the  gruel  one  pint.  If  the  gruel  is  too  thick  for  drinking, 
more  boiled  water  may  be  added.  The  gruel  thus  prepared  is  used  as 
a  "stock."  It  may  be  given  plain,  with  salt  or  with  sugar,  or  both.  I 
frequently  add,  as  flavoring,  two  or  three  ounces  of  chicken  or  mutton 
broth.  From  six  to  eight  ounces  of  t'he  gruel  are  given  every  three 
hours — five  or  six  feedings  in  the  twenty-four  hours.  The  patient  is 
encouraged  to  drink  water,  which  is  given  between  feedings.  Lemon- 
ade, tea,  and  weak  coffee  may  also  be  given  between  the  feedings. 
Rice  or  other  light  cereal,  which  has  been  boiled  for  at  least  four  hours, 
is  given  once  or  twice  daily.  It  is  best  served  with  plenty  of  butter  and 
sugar.     This  with  the  view  of  increasing  the  caloric  content  of  the  food. 

The  diet  schedule  for  a  typhoid  patient,  aged  five  years,  would  be 
practically  as  follows: 

6  A.M.:  Eight  ounces  of  gruel  with  sugar  or  a  small  amount  of 

broth  added.     Zwieback  or  dried  bread  and  butter. 
8  A.  M. :  A  drink  of  weak  tea  with  sugar,  or  the  whites  of  one  or 

two  eggs  with  sugar  in  orange-juice. 
10  A.  M. :  Farina,  cream  of  wheat,  rice,  served  with  butter  and 

sugar,  or  maple-syrup  and  butter.     Drink  of  weak  tea  or 

kumyss  or  matzoon,  or  perhaps  a  dried  milk  food,  such  as 
.     malted  milk  or  Nestle's  food. 
2  p.  M.:  Eight  ounces  of  kumyss,  matzoon,  or  skimmed  milk 

diluted  with  gruel.     Zwieback  or  dried  bread  and  butter  if 

wanted. 
4  p.  M. :  Orange-egg  sherbet,  or  a  drink  of  lemonade  or  tea  and 

sugar. 
6  p.  M.:  Cereal  (or  gruel)  with  sugar  and  butter  or  with  broth. 

If  skimmed  milk  has  not  been  given  at  2  p.  m.,  it  may  be  given 

with  cereal  at  this  time. 
10  p.  M.:  Gruel  with  sugar  or  broth,  or  with  wine. 

Later,  when  the  tongue  becomes  clear  and  the  breath  loses  its 
characteristic  odor,  scraped  rare  beef,  and  soft-boiled  eggs  may  be 
allowed.  With  the  use  of  the  more  substantial  foods,  the  number  of 
feedings  in  the  twenty-four  hours  is  to  be  reduced  to  four. 

It  will  be  seen  that  the  caloric  requirements,  60  to  70  per  kilo,  for 
the  five-year-old  child,  may  easily  be  supplied  by  the  above  arrange- 
ments of  the  feeding,  although  the  diet  arranged  may  not  be  an  ideally 
balanced  one.  It  would  be  high  in  carbohydrates,  rather  low  in  fat, 
and  perhaps  deficient  in  proteid,  particularly  during  the  earlier  period 
of  the  treatment. 

Fat  in  considerable  quantity  is  poorly  digested  by  young  typhoid- 


TYPHOID    FEVER  663 

fever  patients.  It  may  be  given,  however,  in  small  amounts  when 
mixed  with  other  foods.  Foods  containing  proteid  should  not  be  given 
in  considerable  amount  until  we  can  predict  the  course  of  the  disease. 
Milk,  scraped  beef,  and  soft-boiled  eggs  are  not  well  borne  by  young 
typhoid  patients,  and  a  temporary  reduction  of  proteid  is  not  felt  by 
them. 

Carbohydrates,  such  as  the  cereals  and  the  different  sugars,  are 
readily  cared  for  when  properly  prepared  and  administered.  They 
supply  fuel,  but  no  by-products,  and  do  not  require  immediate  elimina- 
tion from  the  body.  Excessive  emaciation  is  prevented  through  their 
action  as  proteid  sparers.  Mendel  and  Rose,  in  the  Journal  of  Biological 
Chemistry,  state  that  they  found  that  the  excretion  of  creatin  induced 
by  starvation  is  inhibited  in  rabbits  by  feeding  a  diet  of  carbohydrates, 
absolutely  free  from  proteids  and  fats.  When  the  carbohydrates  are 
given  in  liberal  amounts,  the  creatin  entirely  disappears  from  the  urine. 
The  creatin  eliminated  is  not  reduced  by  feeding  a  diet  of  fat  alone  or 
by  a  diet  of  fat  and  proteid.  Experimental  interference  with  carbo- 
hydrate metabolism  leads  to  the  elimination  of  creatin,  the  presence  of 
the  creatin  being  due  to  a  true  tissue,  or  endogenous  metabolism. 

Milk  should  not  be  given  in  any  considerable  amount  before  the 
temperature  has  been  normal  for  one  week.  Even  then,  in  a  case  in 
which  no  milk  has  been  given  and  in  which  there  have  been  pronounced 
elevation  of  temperature  and  intestinal  disturbance,  the  giving  of  milk 
may  cause  a  rise  in  the  temperature.  In  not  a  few  cases  in  which  the 
temperature  was  running  a  low  course — from  100°  to  102°F. — without 
the  presence  of  tympanites  or  delirium,  I  have  seen  it  shoot  up  to 
105, 5°F.  and  the  tongue  become  furred  and  the  abdomen  distended 
as  a  result  of  the  administration  of  milk. 

Illustrative  Case. — A  few  years  ago  a  girl,  twelve  years  of  age,  had  typhoid 
fever.  The  temperature  was  not  high,  the  range  being  from  101°  to  103°F.  In 
fact,  fever  and  an  enlarged  spleen  were  the  only  signs  of  the  disease,  until  the 
diagnosis  was  confirmed  by  a  positive  Widal  reaction.  The  tongue  was  moist 
throughout  the  illness,  as  is  not  unusual  when  milk  is  not  given.  The  family  were 
fearful  that  the  patient  was  not  being  sufficiently  nourished.  The  mother  had 
been  told  by  a  physician,  a  family  friend,  that  such  was  the  case.  She  begged 
that  I  allow  the  girl  one  glass,  eight  ounces,  of  full  milk  daily.  I  immediately 
ordered  the  nurse  to  give  the  patient  one  glass  of  Walker-Gordon  milk  once  in 
twenty-four  hours.  She  did  so,  and  in  three  hours  after  the  first  glass  there  was 
a  rise  in  temperature  to  106°F.,  with  abdominal  pain  and  distention.  One  bottle 
of  the  citrate  of  magnesia  and  a  high  enema  were  given,  after  which  the  disease 
resumed  its  usual  course  under  the  previous  diet,  without  milk,  the  temperature 
not  going  above  99°F.  after  the  seventeenth  day.  An  uneventful  convalescence 
followed. 

Mortahty  statistics  do  not  teach  us  all  that  may  be  learned  regard- 
ing the  disease  or  a  method  of  treatment.  The  time  element,  as  related 
to  the  duration  of  the  illness  and  the  duration  of  the  convalescence,  is 
important.  My  observation  in  the  milk-fed  cases  is  that  the  illness  is 
more  severe,  increasing  the  danger  to  life,  and  that  the  duration  of  the 
illness  is  longer.  Emaciation  is  much  greater,  and  the  convalescence 
is  consequently  much  more  protracted  than  under  the  feeding  I  have 
indicated.     The  case  in  which  the  temperature  period  is  cut  down  to 


664  THE    PRACTICE    OF   PEDIATRICS 

fourteen  to  twenty  days,  and  in  which  there  is  Uttle  emaciation  and  a 
prompt  convalescence,  should  not  be  put  in  the  same  class  with  the  case 
in  which  the  fever  lasts  from  thirty  to  fifty  days  or  longer,  with  a  con- 
valescence of  three  or  four  months,  although  both  patients  have  had 
typhoid  fever  and  both  have  recovered. 

It  is  argued  that  milk  constitutes  the  ideal  diet,  for  the  reason  that 
it  contains  all  the  nutritional  elements  required  by  the  organism, — fat, 
proteid,  carbohydrate,  and  mineral  salts, — which  is  the  truth.  It  is 
further  claimed  that  milk  may  be  taken  in  large  quantities  and  be 
readily  digested,  which  is  not  true  in  the  case  of  sick  children.  The 
addition  of  pepsin,  hydrochloric  acid,  etc.,  has  been  of  no  value.  I  have 
learned  that  in  order  to  have  a  short  case  and  a  mild  case  the  abdomen 
must  be  kept  flat.  Tympanites  is  an  indication  of  danger,  regardless 
of  how  it  is  produced.  On  the  milk  diet,  tympanites  is  the  rule.  On 
the  mixed  diet  suggested  it  is  the  exception.  So  long  as  I  can  keep 
the  belly  flat  I  know  that  I  have  the  case  reasonably  in  hand. 

Drugs. — With  the  so-called  intestinal  antiseptics  in  typhoid  fever, 
my  experience  has  been  most  unsatisfactory,  so  far  as  concerns  their 
influence  upon  the  disease.  If  there  is  constipation,  the  citrate  of 
magnesia,  from  four  to  six  ounces,  given  cold,  is  grateful  to  the  patient 
and  usually  proves  effective  If  the  bowels  do  not  move  once  in 
twenty-four  hours,  a  high  enema  should  be  given.  The  digestive 
capacity  is  indicated  by  the  condition  of  the  tongue  and  may  be  improved 
by  the  use  of  dilute  hydrochloric  acid  and  the  tincture  of  nux 
vomica.  The  following  will  be  suitable  for  a  child  from  five  to  ten 
years  of  age: 

I^     Tinct.urae  nucis  vomicae gtt.  xlviij 

Acidi  hydrochlorici  diluti gtt.  cxx 

Glycerini : §iss 

Aquse  destillatse q.  s.  ad  5iv 

M.  Sig. — One  teaspoonful  in  water  after  each  meal. 

As  many  as  four  bowel  passages  in  twenty-four  hours  may  occur 
>vithout  harm  to  the  patient.  In  fact,  I  consider  from  two  to  four  nec- 
essary to  maintain  free  drainage.  When  there  are  more  than  six  in 
twenty-four  hours,  loose  and  watery  in  character,  the  loss  of  fluids  sus- 
tained may  be  a  serious  factor  in  the  case,  in  causing  a  concentration 
of  the  blood,  with  a  corresponding  concentration  of  the  poison,  as  shown 
in  the  marked  general  toxemia. 

Diarrhea  in  typhoid  is  best  controlled  by  the  use  of  opium  combined 

with  bismuth.     To  a  child  from  three  to  five  years  of  age,  the  following 

may  be  given: 

I^     Pulv.  ipecacuanhse  et  opii gr.  x 

Bismuthi  subnitratis  (Squibb) gr.  c 

M.  Div.  et  ft.  chart,  no.  x. 

Sig. — One  every  three  hours  until  the  stools  diminish  in  frequency, 
then  give  at  intervals  of  six  to  twelve  hours  if  necessary. 

For  children  from  one  to  three  years  old  the  dose  of  the  Dover's 
powder  should  be  reduced  one-half,  the  fuU  amount  of  the  bismuth 
being  given.     The  amount  required  to  keep  the  diarrhea  under  control 


TYPHOID    FEVER  665 

will  soon  be  learned.  Of  course,  constipation  must  not  be  produced, 
for  if  a  free  bowel  action  is  interfered  with,  there  will  be  increased  pros- 
tration and  higher  temperature. 

Control  of  the  Fever. — A  temperature  at  or  below  104°F.  is  not 
interfered  with,  in  the  great  majority  of  cases.  Of  course,  a  very  deli- 
cate child  with  a  weakened  heart  action  may  require  the  use  of  anti- 
pyretic measures  before  this  temperature  is  reached.  This  necessity, 
however,  is  unusual.  My  observation  is  that  when  the  temperature  is 
above  104°F.,  the  patient  does  better  if  proper  means  are  used  for  its 
control. 

Antipyretic  drugs  are  rarely  given.  Quinin,  in  my  cases,  has 
never  proved  of  the  shghtest  value,  even  when  given  in  large  doses — 15 
or  20  grains  in  twenty-four  hours  to  a  child  five  years  of  age.  The 
coal-tar  products,  such  as  phenacetin,  may  be  used  in  small  doses 
without  harm,  if  hydrotherapy  is  not  applicable,  as  in  a  case  which 
I  recently  saw  in  a  remote  country  district. 

Illustralive  Case. — The  patient  was  a  boy  six  years  of  age.  He  was  delirious  at 
times,  tossing  almost  constantly  about  the  bed,  and  sleeping  but  little,  with  a 
temperature  ranging  from  105°  to  106°F.  The  disease  period  was  the  latter  part 
of  the  second  week,  and  the  patient  was  becoming  rapidly  exhausted.  The  parents, 
densely  ignorant,  refused  to  allow  the  bath  or  pack.  Sponging,  which  was  carried 
out  indifferently,  had  not  the  slightest  effect  on  the  temperature  and  appeared  to 
excite  the  patient.  It  was  suggested  to  the  attending  physician  that  he  give  two 
grains  of  phenacetin  and  one-half  grain  of  the  citrate  of  caffein  at  intervals  of  three 
to  six  hours.  From  four  to  six  powders  daily  were  required  to  keep  the  fever 
within  the  desired  bounds  and  the  skin  moist.  This  medicine  had  a  decidedly 
quieting  effect  upon  the  patient,  whose  heart  action  was  in  no  way  unfavorably 
influenced  and  who  made  a  complete  recovery.  Had  the  great  restlessness,  the 
loss  of  sleep,  and  the  delirium  continued  I  have  no  doubt  there  would  have  been 
a  fatal  termination. 

While  there  is  much  truth  in  what  has  been  written  concerning  the 
depressing  effects  of  the  coal-tar  products,  and  while  the  dangers  from 
their  excessive  use  are  realized,  on  certain  occasions  they  are  a  neces- 
sity. I  cannot  help  feeling  that  the  dangers  have  been  exaggerated. 
Probably  the  diseases  in  which  the  use  of  such  drugs  is  most  dangerous 
are  pneumonia  and  the  inflammatory  conditions  of  the  heart. 

Heart  Stimulants. — If  the  heart,  by  the  rapidity  of  its  action,  shows 
signs  of  failure,  the  tincture  of  strophanthus  is  our  best  remedy.  When 
there  is  irregularity  in  force  and  rhythm,  strychnin  should  be  used.  A 
child  from  five  to  ten  years  of  age  may  be  given  two  drops  of  the  tinc- 
ture of  strophanthus  at  intervals  of  two  to  four  hours.  Strychnin, 
3^0  grain,  at  intervals  of  three  to  four  hours,  may  be  given  for  the  same 
age.  Alcohol  should  not  be  given  as  a  heart  stimulant  until  other 
means  have  failed.  It  is  a  drug  to  be  used  only  in  conditions  of  great 
stress.  Its  function  is  to  carry  us  over  and  out  of  difficult  places,  and 
it  may  be  given  in  the  form  of  whisky  or  brandy,  one  to  three  drams  at 
intervals  of  two  to  four  hours  in  children  from  three  to  ten  years  of  age. 
Its  continued  administration  for  a  considerable  period  is  not  to  be  ad- 
vised. In  any  disease  it  is  difficult  to  lay  down  definite  rules  for  the 
administration  of  heart  stimulants.  They  are  used  with  the  hope  of 
producing  a  definite  effect,  and  when  such  effects  are  produced,  a  larger 


666  THE    PRACTICE    OF    PEDIATRICS 

quantity  should  not  be  given.  It  is  best  always  to  begin  with  small 
doses  and  gradually  increase  until  the  desired  results  are  apparent. 

Hydrotherapy. — Pyrexia  is  best  controlled  by  hydrotherapy. 

Sponging  with  lukewarm  or  cool  water  may  be  tried,  and  if  the  case 
is  not  severe,  this  may  answer.  The  child  may  be  sponged  with  water 
at  from  80°  to  70°F.  for  one-half  hour  out  of  every  two  or  three  hours. 
Sponging,  however,  even  if  it  controls  the  temperature,  may  not  be  the 
best  means  of  using  water  for  this  purpose,  for  the  reason  that  many 
children  object  to  it,  and  in  consequence  the  sponging  disturbs  them, 
increasing  their  irritability  and  reducing  their  vitality. 

The  use  of  the  bath  for  the  reduction  of  fever  in  children  I  have  dis- 
continued. They  invariably  object  to  it,  the  bath  excites  or  frightens 
them,  and,  as  a  rule,  particularly  in  the  very  young  and  delicate,  the  re- 
action following  it  is  poor.  Moreover,  the  bath  necessitates  a  great 
deal  of  handling,  undressing  and  dressing,  and  therefore  tires  the 
patient. 

Reduction  of  the  temperature  by  means  of  a  rectal  irrigation  with 
cool  water  has  its  advocates.  If  the  temperature  is  running  high  and 
intestinal  lavage  is  indicated  for  reasons  other  than  the  temperature, 
lavage  may  be  used  here,  the  water  being  of  a  lower  temperature  than 
that  of  the  body,  though  I  never  use  it  lower  than  80°F.  for  this 
purpose.  Without  a  high  body-temperature,  however,  and  other  indi- 
cations as  well,  irrigation  is  never  to  be  used.  It  causes  straining, 
excites  the  child,  and  thus  increases  the  danger  of  hemorrhage  and  per- 
foration. Furthermore,  it  is  a  very  indifferent  antipyretic,  even  when 
used  with  water  as  cold  as  75°F. 

By  far  the  best  means  of  reducing  the  temperature  in  children  is 
the  cool  pack  (p.  777).  Its  advantages  are  that  it  causes  no  fright 
or  shock,  the  child  being  disturbed  comparatively  little  by  it.  He 
may  be  placed  in  a  towel,  which  has  been  wet  with  water  at  95°F., 
and  the  only  manipulation  necessary  is  to  turn  him  from  side  to  side, 
so  that  the  towel  may  be  kept  constantly  wet  with  cool  water  at  the 
desired  temperature.  The  pack  more  effectually  controls  the  tempera- 
ture than  does  either  sponging  or  the  tub-bath.  As  suggested  else- 
where (see  p.  778),  the  child  should  be  removed  from  the  pack  when 
his  temperature  falls  to  102°F. 

Hemorrhage  and  Perforation.-^Hemorrhage  has  not  occurred  in 
any  of  my  cases  in  which  the  non-milk  diet  was  given.  In  the  event 
of  hemorrhage  the  cold  coil  or  the  ice-bag  should  be  applied  and  Dover's 
powder  given  in  full  doses  to  control  peristalsis.  In  case  of  perforation, 
operative  procedure  is  to  be  resorted  to,  but  this  holds  out  little  hope. 
Children  bear  abdominal  operations  badly,  and,  considering  the  ex- 
hausted condition  of  a  young  child  in  the  third  or  fourth  week  of  a 
severe  typhoid,  the  outlook  is  most  unfavorable. 

MALARIA 

Malaria  is  caused  by  the  Plasmodium  malarise,  a  protozoon  dis- 
covered by  Laveran  in  1881. 


MALARIA  667 

Species. — Three  species  of  Plasmodium  are  recognized,  that  caus- 
ing tertian  malarial  fever,  that  causing  quartan  malarial  fever,  and 
that  causing  malaria  of  the  estivo-autumnal  type. 

The  tertian  malarial  parasite,  which  is  the  most  common  form,  com- 
pletes its  development  in  the  blood  in  forty-eight  hours,  and  produces 
a  malarial  paroxysm  every  second  day.  When  fully  grown,  the  tertian 
parasite  is  much  larger  than  the  quartan  variety,  which  sporulates  in 
seventy-two  hours.  The  estivo-autumnal  parasite  produces  the  remit- 
tent form  of  malarial  fever,  with  varying  intervals  between  the  par- 
oxysms. The  characteristic  form  of  this  Plasmodium  is  the  pigmented 
crescent. 

The  Plasmodia  of  malaria  enter  the  red  blood-cells  and  live  at  their 
expense.  The  resulting  anemia  is  due  to  the  destruction  of  the  large 
number  of  erythrocytes,  the  parasites  deriving  their  pigment  from  the 
hemoglobin  of  the  red  corpuscles  upon  which  they  have  fed. 

Transmission. — Malaria  is  transmitted  from  one  human  subject  to 
another  by  the  bite  of  the  Anopheles,  a  species  of  mosquito. 

The  fully  developed  parasites  are  most  readily  found  in  the  blood 
an  hour  or  two  before  the  onset  of  the  paroxysm.' 

Craig  states  that  in  malarial  localities  children  suffer  much  more 
severely  from  the  disease  than  do  adults,  and  that  malaria  is  often 
latent  in  young  subjects.  The  disease  may  occur  in  very  young  in- 
fants, but  is  always  of  postnatal  origin.  Thayer  and  others  have 
shown  conclusively  that  malarial  parasites  are  not  transmitted  through 
the  placental  circulation. 

Malarial  fever  contracted  in  New  York  city  is  of  very  unusual  oc- 
currence. Patients  coming  under  my  observation  have,  with  few  ex- 
ceptions, resided  elsewhere,  or  contracted  the  disease  while  in  the 
country  during  the  summer.  Every  autumn  a  few  cases  of  such  origin 
are  treated.     They  are  usually  of  the  tertian  type. 

Pathoiogy. — The  most  marked  pathologic  changes  in  malaria  are 
found  in  the  blood,  since  the  plasmodia  feed  upon  the  red  blood-cor- 
puscles. As  a  result,  there  is  a  marked  reduction  in  the  number  of 
erythrocytes  and  in  the  amount  of  hemoglobin;  there  is,  further,  the 
production  of  a  large  amount  of  black  and  brownish  yellow  pigment. 
The  leukocytes  are  also  decreased  in  number,  while  there  is  a  relative 
increase  of  large  mononuclear  cells. 

At  autopsy  upon  patients  dying  of  pernicious  malaria  characteristic 
lesions  are  found  in  the  brain,  spleen,  and  liver.  The  brain  usually 
shows  congestion  and  capillary  hemorrhages  due  to  blocking  and  rup- 
ture of  the  capillaries  by  plasmodia  and  pigment.  There  may  be  pig- 
mentation of  the  gray  matter.  The  capillaries  contain  infected  blood- 
corpuscles,  free  plasmodia,  free  pigment,  macrophages  often  large 
enough  to  block  the  vessel,  and  pigmented  leukocytes.  The  nerve- 
cells  show  marked  degenerative  changes. 

The  liver  is  enlarged,  fatty,  pigmented,  and  congested.  In  the 
capillaries  malarial  plasmodia  and  pigment  are  seen  within  macro- 
phages, but  only  very  few  plasmodia  are  found  within  red  blood-cells. 


668  THE    PRACTICE    OF   PEDIATRICS 

The  liver-cells  are  degenerated,  and  sometimes  pressed  out  of  existence 
by  the  distended  capillaries.  Areas  of  focal  necrosis  occur  with  an 
increase  in  the  connective  tissue  around  them. 

The  spleen  is  enlarged  and  pigmented,  and  the  pulp  is  soft  and  dark 
colored.  The  venous  sinuses  are  congested,  and  there  are  many  Plas- 
modia free  in  red  blood-cells,  in  macrophages,  and  in  smaller  cells ;  there 
is  also  free  pigment.  The  splenic  connective  tissue  is  increased  only 
in  those  cases  in  which  repeated  attacks  of  malaria  have  occurred. 

The  other  viscera  do  not  show  specific  lesions  of  any  kind.  All  the 
capillaries  contain  malarial  plasmodia,  and  there  is  present  more  or 
less  pigmentation.  The  epithelial  cells  of  the  kidneys  and  adrenals 
are  usually  degenerated  as  the  result  of  the  toxemia.  The  heart  may 
be  flabby  and  anemic.  The  lungs  may  show  congestion,  edema,  or 
bronchopneumonia. 

Symptoms. — The  symptoms  vary  somewhat  with  the  age  of  the 
patient;  thus  an  infant,  instead  of  giving  evidence  of  a  chill,  which 
signals  the  onset  in  older  children,  becomes  cold,  blue,  and  pinched  in 
appearance.  Vomiting  or  convulsions  may  take  the  place  of  a  chill. 
Whatever  the  nature  of  the  immediate  onset,  fever  follows,  which  rarely 
continues  longer  than  five  or  six  hours.  This  stage  may  not  be  followed 
by  sweating.  About  the  same  time,  on  the  following  day  or  the  day 
after,  the  same  phenomenon  is  repeated.  The  patient  is  very  com- 
fortable between  the  seizures. 

Physical  Examination. — Physical  examination  of  the  patient  will 
reveal  enlargement  of  the  spleen,  a  condition  almost  invariably  present 
in  malaria  in  children.  In  neglected  cases  signs  of  malnutrition  rapidly 
develop  regardless  of  the  age.  They  differ  in  no  way,  however,  from 
those  dependent  upon  febrile  conditions  due  to  other  causes. 

Relapse. — When  relapse  occurs,  it  means  one  of  two  conditions — • 
reinfection,  or  a  case  not  cured.  A  relapse  after  weeks  or  months  is 
not  uncommon.  In  my  observation,  in  cases  which  have  been  treated 
with  quinin  for  only  a  week  or  two,  until  the  active  symptoms  subside, 
after  a  certain  time,  another  sharp  attack  results.  The  manifestations 
are  occasionally  milder.  There  is,  perhaps,  a  low  periodic  temperature 
without  chill,  the  temperature  not  reaching  a  point  above  101°  or  102° 
F.  I  have  time  and  again  had  this  feature  of  the  disease  brought  to 
my  attention.  These  cases  represent  what  is  sometimes  designated 
as  chronic  malarial  poisoning  or  persistent  malarial  infection.  In  non- 
malarial  sections  reinfection  is  an  improbability. 

Diagnosis. — The  positive  diagnosis  of  malaria  depends  upon  finding 
the  malarial  organism  in  the  blood,  provided,  of  course,  that  quinin 
has  not  been  previously  given. 

The  next  best  means  of  diagnosis  consists  in  the  use,  in  suspicious 
cases,  of  adequate  doses  of  an  assimilable  preparation  of  quinin.  An 
immediate  control  of  the  temperature  is  strong  presumptive  evidence 
that  malaria  has  existed.  When  full  doses  of  quinin  do  not  control 
the  temperature,  this  fact  usually  means  that  malaria  does  not  exist 
and  that  there  are  other  causes  for  the  illness. 


MALARIA  669 

Differential  Diagnosis. — There  are  probably  very  few  diseases  with 
fever  which  have  not  many  times  been  confused  with  malaria.  In  fact, 
the  erroneous  diagnosis  of  malaria  has  probably  been  made  more  often 
than  all  other  diagnostic  errors  combined. 

There  are  many  conditions  in  which  there  may  be  a  remittent  tem- 
perature period,  and  which  may  be  looked  upon  as  malaria;  an  enu- 
meration is  unnecessary.  Probably  elevation  of  temperature  due  to  oc- 
cult pus  is  responsible  for  more  diagnoses  of  malaria  than  is  any  other 
agency.  Influenza,  typhoid  fever,  tuberculosis,  and  periodic  fever 
due  to  fatigue  often  have  the  diagnosis  of  malaria  attached  to  the  ail- 
ment. With  blood  examinations  and  the  various  newer  diagnostic 
methods  there  is  no  occasion  for  errors  in  differentiation. 

Prophylaxis. — The  prophylaxis  consists  entirely  in  keeping  the 
child  free  from  the  anopheles  mosquito. 

Treatment. — When  it  is  demonstrated  that  malaria  exists,  quinin 
should  be  given  in  what  may  be  considered  large  doses,  if  we  are  to  use 
the  adult  for  comparison.  Children  tolerate  quinin  well ;  in  fact,  to  be 
effective,  a  much  larger  amount  comparatively  is  required  than  in 
adults.  In  giving  quinin  to  young  children  care  must  be  used  in  its 
administration  lest  it  excite  vomiting.  For  this  reason  it  should  be 
given  after  meals  in  solution  or  in  capsule.  The  best  menstruum  is  a 
preparation  of  yerba  santa,  known  as  Yerberzine.*  A  child  under 
eighteen  months  of  age  will  require  from  8  to  12  grains  of  quinin  daily. 
Two  to  three  grains  of  the  bisulphate  should  be  given  at  a  dose,  not 
more  than  four  doses  being  given  in  twenty-four  hours. 

When  I  was  resident  physician  at  the  New  York  Infant  Asylum, 
then  located  in  southern  Westchester  County,  New  York,  there  was  a 
great  deal  of  malaria  among  the  women  and  children  inmates.  In  that 
institution  I  repeatedly  gave  infants  under  four  months  of  age  8  grains 
in  twenty-four  hours.  In  some  cases  at  this  age  a  larger  quantity — 
10  to  12  grains — will  be  required.  Quinin  chocolate  tablets  are  some- 
times used  in  giving  the  drug  to  children.  In  using  these  tablets  it 
must  be  remembered  that  the  contained  quinin  is  in  the  form  of  the 
tannate,  and  that  one  grain  of  the  tannate  represents  about  3^  grain  of 
the  sulphate.  If  sufficient  quinin  to  be  of  value  is  given  in  this  form, 
the  large  amount  of  chocolate  in  the  tablet  will  surely  upset  the  diges- 
tion. To  children  under  one  year  of  age  with  whom  Yerberzine  may 
disagree  because  of  the  sugar  which  it  contains,  the  bisulphate  may  be 
given  in  solution  in  distilled  water,  followed  by  a  teaspoonful  of  orange- 
juice.  For  older  children, — from  two  to  six  years  of  age, — from  15  to 
30  grains  daily  will  be  necessary  to  control  the  disease.  To  these,  as 
to  the  younger  children  it  should  be  given  in  Yerberzine  unless  the 
child  can  be  taught  to  take  a  capsule,  when  the  quinin  may  be  given 
in  3-grain  doses  at  two-hour  intervals  until  the  prescribed  daily  amount 
has  been  taken. 

The  giving  of  a  large  dose  of  quinin  a  few  hours  preceding  the  ex- 

*  Made  by  Lilly  and  Co. 


670  THE    PRACTICE    OF    PEDIATRICS 

pected  chill  does  not  answer  well  in  children,  as  a  large  amount  given 
at  one  time  may  frequently  cause  vomiting. 

Special  Methods  of  Administration. — The  use  of  quinin  by  inunction 
or  by  the  rectum  has  not  been  satisfactory.  Its  use  by  these  methods 
was  attempted  at  the  Infant  Asylum  in  a  great  many  cases  where 
difficulty  was  experienced  in  the  stomach-administration. 

With  but  ope  patient,  aged  two  years,  have  I  been  obliged  to  resort 
to  hypodermic  medication.  The  child  showed  the  tertian  parasite, 
and  the  disease  resisted  the  internal  use  of  quinin  in  large  doses,  but 
responded  promptly  to  the  muriate  of  quinin  given  hypodermatically, 
7  grains  being  used  at  one  injection.  There  was  no  abscess  at  the  site 
of  the  injection,  and  the  child  was  permanently  cured.  To  be  sure, 
the  administration  of  quinin  was  continued  by  the  mouth,  but  the 
dosage  of  16  grains  daily  was  now  apparently  effective,  where  pre- 
viously it  had  made  no  impression. 

Recurrence. — The  use  of  quinin  in  malaria  should  not  be  stopped 
abruptly  upon  a  cessation  of  the  fever.  It  is  my  custom  to  give  the 
drug  in  full  doses  for  one  week  after  the  temperature  fails  to  rise  unless 
there  is  a  subnormal  temperature,  in  which  event  the  drug  is  reduced 
one-half  or  temporarily  discontinued.  It  is  a  difficult  matter  to  deter- 
mine when  a  case  of  malaria  is  cured.  Time  and  again  I  have  sup- 
posed that  a  patient  was  well  when  a  recurrence  of  the  paroxysm  took 
place  weeks  afterward.  How  often  this  was  due  to  reinfection,  and 
how  often  to  the  old  infection  which  had  not  been  entirely  eradicated, 
it  is  difficult  to  say.  I  am  inclined  to  the  belief,  however,  that  in 
many  instances  the  Plasmodium  had  remained  inactive  in  the  spleen 
in  spite  of  the  return  of  that  organ  to  nearly  its  normal  size,  for  the 
reason  that  the  recurrence  of  symptoms  sometimes  took  place  coinci- 
dent with  some  other  illness  with  fever,  such  as  tonsillitis  or  acute 
indigestion.  My  experience  with  recurrences  of  the  disease  has  been 
such  that,  after  an  attack  of  malaria,  I  now  direct  that  the  child  be 
given  quinin  for  one  week  out  of  each  month,  for  an  indefinite  time — ■ 
at  least  for  a  year  following  the  original  attack. 

Illustrative  Case. — In  a  comparatively  recent  case,  a  girl  five  years  of  age  had 
repeated  attacks  for  two  years  before  coming  under  my  care.  The  mother  was 
instructed  to  give  the  child  12  grains  of  the  bisulphate  daily  for  seven  days  out 
of  each  month.  This,  without  a  change  of  residence,  was  sufl&cient  to  prevent  a 
recurrence  during  the  fifteen  months  which  followed. 

INFLUENZA 

Influenza  is  an  acute  infectious  disease  due  to  the  Bacillus  influenzae, 
first  described  by  Pfeiffer  as  a  result  of  his  studies  during  the  great 
pandemic  of  1889-90. 

Bacteriologic  Etiology. — It  is  a  slender,  non-motile  rod,  which  stains 
deeply  at  the  poles,  does  not  retain  the  Gram's  stain,  and  is  very  pleo- 
morphic. Its  one  unvarying  characteristic  is  its  utter  inability  to  grow 
in  media  which  do  not  contain  hemoglobin.  On  agar  mixed  with 
human,  pigeon's,  or  rabbit's  blood,  its  cultivation  is  an  easy  matter. 


INFLUENZA 


671 


The  colonies  are  small  and  dew-drop  like,  they  do  not  coalesce,  and 
they  do  not  cause  hemolysis  in  the  surrounding  medium. 

Mode  of  Entrance. — It  is  the  rule  for  the  influenza  bacillus  to  enter 
the  human  body  through  the  upper  respiratory  tract,  whence  it  may 
travel  down  into  the  lung,  causing  bronchitis  or  bronchopneumonia. 
In  comparatively  few  cases  it  is  the  cause  of  otitis  media.  General 
blood  invasion  with  Bacillus  influenzae  is  a  rare  condition,  which  is 
usually,  but  not  invariably,  accompanied  by  purulent  inflammation 
of  one  or  more  serous  membranes — meningitis,  pleuritis,  pericarditis, 
peritonitis,  arthritis. 

Source  of  Infection. — ^The  source  of  infection  is  contact  with  an 
acute  case  of  influenza  or  with  a  carrier.  In  either  instance  the  secre- 
tions from  the  nose  or  bronchi  contain  the  bacilli  in  a  moist  state.  The 
organisms  do  not  resist  drying  long  enough  to  make  clothes  or  linen  a 
probable  source  of  contagion,  but  they  do  remain  viable  for  months  in 


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the  bronchial  secretion  of  cases  of  influenzal  bronchitis,  with  or  without 
bronchiectasis,  and  they  have  been  found  there  six  months  after  an 
attack  of  pertussis  (Davis). 

The  work  at  the  New  York  Babies'  Hospital  (Wollstein)  has  shown 
that  the  influenza  bacillus  is  present  in  the  bronchial  secretion  of  young 
children  far  more  often  than  is  usually  known,  and  that  it  is  not  pres- 
ent as  a  saprophyte.  Patients  suffering  from  tuberculosis  are  very 
prone  to  infection  with  the  influenza  bacillus.  It  may,  in  such  cases, 
by  causing  a  terminal  bronchopneumonia,  be  the  actual  cause  of  death. 

Age. — All  ages  are  susceptible,  particularly  infants  under  one  year. 

Pathology. — Influenza  suppHes  no  distinct  lesion  of  its  own.  In 
the  respiratory  tract,  where  the  bacillus  is  most  active,  there  may  be 
only  tlie  changes  characteristic  of  bronchitis  or  there  may  be  a  broncho- 
pneumonia due  to  B.  influenzae  in  pure  culture.  The  bacillus  is  most 
fertile  in  its  power  of  producing  lesions  in  various  organs,  but  these 
lesions  in  no  sense  differ  from  those  produced  by  other  forms  of 
infection. 


672 


THE    PRACTICE    OF    PEDIATRICS 


Incubation. — The  period  of  incubation  may  be  very  short.  It  is 
rarely  longer  than  seven  days,  and  may  be  but  one  or  two. 

Symptoms. — The  onset  of  influenza  is  usually  with  sneezing,  slight 
conjunctivitis,  and  cough.     There  may  be  a  moderate  fever — from  100° 


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to  103°F.  or  higher.  The  throat  is  reddened,  and  there  may  be  a  few 
coarse  rales  in  the  chest.  The  symptoms  subside,  and  the  child  is  well 
in  five  or  six  days.  After  the  second  year  children  complain  of  head- 
ache and  muscle  soreness ;  there  is  also  a  failure  of  appetite.  This  rep- 
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Severe  cases  show  the  above  signs,  with  the  exception  that  there  are 
higher  fever  and  much  greater  prostration.  Convulsions  are  unusual, 
but  headache  and  extreme  restlessness  are  often  present. 

Cough. — The  cough  in  the  severe  type  is  often  most  troublesome. 


INFLUENZA 


673 


The  most  severe  coughs  do  not  occur,  necessarily,  when  bronchitis  is 
a  comphcation.  The  hard,  persistent  cough,  without  expectoration, 
without  rales,  or  with  but  a  few  rales  in  the  chest,  may  be  said  to 
typify  the  cough  of  influenza.  Every  year  I  see  patient  after  patient 
who  has  the  nagging  tracheal  cough  not  only  during  the  attack,  but 


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sometimes  for  weeks  afterward,  without  a  sign  in  the  throat  other  than 
perhaps  unusual  redness,  and  without  a  chest  sign.  The  influenza 
bacillus  seems  to  have  a  special  tendency  for  localization  in  the  trachea. 
G astro-intestinal  Manifestations. — Occasionally  grip  is  ushered  in 
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ing,  no  food  being  retained  for  twenty-four  to  forty-eight  hours.  Pro- 
nounced intestinal  disturbance  is  by  no  means  an  unusual  evidence  of 
infection  with  the  influenza  bacillus;  there  may  be  diarrhea  without 
any  evidence  of  involvement  of  the  intestinal  structure,  or  there  may 
be  colitis  with  tenesmus  and  mucus  and  blood  in  the  stools.  In  not  a 
43 


674 


THE    PRACTICE    OF    PEDIATRICS 


few  cases  the  so-called  complications  are  the  only  manifestations  of  the 
infection.  This  has  led  writers  to  describe  a  "grip  colitis,"  a  "grip 
gastritis,"  etc. 

The  Temperature. — The  temperature  characteristics  of  influenza 
are  peculiar.  There  is  a  tendency  to  wide,  irregular  variations  from 
normal  to  105°  or  106°F.  and  back  again.  I  have  repeatedly  known 
the  temperature  to  range  from  100°  to  103°  or  104°F.  for  six  or  eight 
weeks  (see  charts),  without  other  lesion  than  that  of  a  catarrhal  brpn- 
chitis.  A  peculiar  feature  of  these  uncomplicated  grip  cases  is  the 
height  to  which  the  temperature  will  rise  daily  and  its  long  continua- 
tion for  many  days  with  insignificant  signs  of  illness  and  absence  of 
effects  on  the  patient. 

Fatal  Cases. — Fatalities  from  uncomplicated  influenza  are  unusual. 


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/ 

J 

, 

Fig.  95. — Prolonged  influenzal  infection. — (Concluded.) 


Illustralive  Cases. — Two  cases  of  grip  in  infants  in  which  the  diagnosis  was  made 
by  exclusion  and  verified  by  autopsy  occurred  at  the  County  Branch  of  the  New 
York  Infant  Asylum  during  the  winter  of  1888  and  1889,  which,  it  will  be  remem- 
bered, was  the  time  when  grip  first  visited  this  country  in  epidemic  form.  These 
healthy,  breast-fed  babies  were  taken  with  the  disease,  together  with  about  40 
other  inmates,  mothers  and  children,  in  one  of  the  large  wards.  The  infants  in 
question,  aged  three  and  four  months  respectively,  were  stricken  suddenly  with 
high  fever  and  marked  prostration.  They  quickly  went  into  a  condition  of  col- 
lapse, and  both  died  in  less  than  thirty-six  hours  from  the  onset.  The  autopsy 
failed  to  show  any  pathologic  change  other  than  a  slight  hypostatic  congestion  of 
the  lungs. 

Complications. — The  influenza  bacillus  alone  may  produce  otitis, 
meningitis,  pericarditis,  periarthritis,  peritonitis,  and  nephritis  of  the 
hemorrhagic  type.  The  chief  danger  attending  its  invasion  of  the 
body  is  its  ability  to  prepare  a  field  for  the  development  of  other  patho- 
genic organisms. 

The  most  frequent  complication  of  grip  is  bronchitis,  and  the  most 
fatal  complication  is  hronchopneumonia. 

Suppurative  otitis  is  not  an  infrequent  complication;  perhaps  it 
would  be  better  to  class  it  as  a  grip  sequela.  Among  72  cases  of  acute 
suppurative  otitis  referred  to  elsewhere,  59,  or  81.9  per  cent.,  occurred 
with  or  followed  immediately  upon  an  attack  of  grip.     Patients  who^ 


INFLUENZA  675 

after  an  attack  of  grip,  run  a  temperature  without  any  apparent  cause, 
should  be  examined  by  a  skilled  otologist. 

Adenitis  is  a  complication  in  many  cases,  I  have  seen  cases  of 
endocarditis  associated  with  grip. 

The  Kidneys. — In  nearly  all  cases  of  severe  infection  a  slight  amount 
of  albumin  will  be  present  in  the  urine  during  the  entire  period,  and 
occasionally,  in  a  few  cases,  hyaline  and  granular  casts  will  be  found. 
The  irritation  is  only  of  temporary  duration,  and  subsides  after  a  few 
days. 

In  a  very  large  experience  with  all  types  of  influenza  I  have  never 
known  the  association  of  acute  parenchymatous  nephritis  with  grip, 
such  as  occurs  with  scarlet  fever  or  the  other  exanthemata. 

Every  year  I  see  about  six  cases  of  acute  hemorrhagic  nephritis 
complicating  influenza.  These  cases  are  peculiar  in  that  there  is  a 
large  amount  of  blood  with  few  hyaline  and  epithelial  casts.  There  is 
little  or  no  suppression  of  the  urine  and  no  edema  or  sign  of  nephritis  ex- 
cepting the  urinary  findings.  I  have  never  lost  a  case  although  micro- 
scopic blood  and  casts  have  been  present  in  the  urine  for  several  weeks. 

Duration. — The  duration  may  be  two  or  three  days,  or  it  may  be 
two  or  three  months.  One  attack  of  the  disease  confers  no  immunity. 
The  long-continued  cases  are  those  of  reinfection  and  recrudescence. 

Prognosis. — The  prognosis  of  influenza  is  favorable  in  the  absence 
of  complications.  With  complications  the  outcome  depends  upon  the 
nature  of  the  associated  disease.  Further,  it  is  to  be  remembered  that, 
as  a  complication  of  bronchitis  and  pneumonia,  influenza  supplies  a 
decided  additional  danger. 

Diagnosis. — From  simple  internal  colds  a  differentiation  may  be 
impossible  without  a  bacteriologic  examination.  In  influenza  there  is 
a  tendency  to  chronicity  and  reinfection,  with  widely  fluctuating  tem- 
perature, irregular  as  to  rise  and  fall.  It  seems  most  difficult  for  the 
patient  completely  to  recover.  Meningitis,  malaria,  and  typhoid  fever 
may  be  confused  with  grip,  but  may  be  readily  differentiated  by  the 
well-known  diagnostic  methods.  In  any  case  of  influenza  the  ears 
should  be  subjected  to  daily  examination,  as  otitis  may  cause  an  eleva- 
tion of  temperature  identical  with  that  of  a  protracted  case  of  uncom- 
plicated influenza. 

Sequelae. — After  even  a  moderately  severe  attack  of  grip  the 
patient  is  left  in  a  condition  that  is  peculiar  to  this  disease  and  none 
other.  He  is  habitually  tired,  easily  fatigued  upon  slight  exertion, 
shows  but  little  tendency  to  take  up  active  play,  and,  if  older,  finds 
school  work  very  difficult.  In  a  large  proportion  of  cases  there  will  be  a 
slight  elevation  of  temperature  nearly  every  day — rarely  higher  than 
101°F.  A  feature  of  these  temperature  cases  is  that  the  attack  may 
not  have  been  at  all  severe.  Every  winter  and  spring  I  am  repeatedly 
consulted  about  the  tendency  to  elevation  of  temperature  after  grip. 
In  some  cases  the  temperature  will  continue  for  months.  It  will  be 
normal — 98.5°  to  99°F. — in  the  morning,  perhaps  100°F,  or  thereabouts 
at  noon,  and  101°,  or  101°F.  and  a  fraction  at  night.     It  rarely  reaches 


676  THE    PRACTICE    OF    PEDIATRICS 

102°F.  The  persistent  temperature  cases  are  not  due  to  disease  proc- 
esses or  to  the  presence  of  the  influenza  bacillus  in  the  bronchial 
tract,  as  has  been  claimed,  but  to  constitutional  weakness  and  fatigue. 
In  some  way,  through  the  action  of  the  toxins  of  the  disease,  the  heat- 
regulating  center  becomes  involved,  and  through  activities  which 
ordinarily  would  not  produce  any  effect  an  influence  is  exerted  causing 
an  elevation  of  the  temperature.  That  a  portion  of  this  deduction  is 
correct  may  be  readily  proved  by  keeping  these  patients  quiet  in  bed 
for  three  days,  and  taking  their  temperature  at  the  usual  intervals, 
morning,  noon,  and  night  (6  p.  m.).  It  will  be  found,  if  they  are  kept 
quiet  and  the  bowels  active,  that  the  temperature  will  remain  within 
the  normal  limits — not  above  99°F.  I  have  demonstrated  this  in  a 
great  many  cases.  If  it  continues  uninfluenced,  there  is  a  discernible 
cause  which  should  be  discovered.  After  grip,  because  of  the  child's 
low  physical  state,  he  is  often  urged  to  take  more  food  than  he  can 
assimilate,  and  there  may  be  a  mild  degree  of  intestinal  indigestion, 
producing  sufficient  toxic  effects  to  cause  the  temperature,  yet  unob- 
served because  of  the  absence  of  active  symptoms.  I  have  known  the 
free  use  of  milk  and  cream  to  produce  a  slight  persistent  elevation  of 
the  temperature  after  grip.  Tuberculosis  of  the  bronchial  glands  may 
produce  a  similar  but  not  persistent  temperature  range. 

Quarantine. — Individuals  with  influenza  should  be  quarantined 
(p.  649)  from  other  members  of  the  household.  Older  members  of 
the  household  are  often  the  bacillus  carriers  and  infect  the  younger 
members. 

One  attack  of  grip  confers  no  immunity  upon  the  patient;  in  fact, 
patients  apparently  reinfect  themselves.  For  this  reason  I  always 
advise  that  two  rooms  be  used,  when  possible,  one  for  the  day  and  one 
for  the  night,  the  room  not  occupied  during  the  day  being  aired  for  sev- 
eral hours  with  all  the  windows  open.  After  recovery,  the  sick-rooms 
should  be  thoroughly  aired,  cleaned,  and  fumigated  with  sulphur,  for- 
maldehyd,  or  chlorin  gas. 

Treatment. — The  individual  treatment  is  symptomatic.  The 
rhinitis  and  bronchitis  are  treated  as  if  the  condition  were  not  grip. 

The  management  of  an  otitis,  pneumonia,  bronchitis,  or  colitis  as- 
sociated with  or  following  an  attack  of  influenza,  differs  in  no  way,  so 
far  as  the  immediate  treatment  of  the  complication  is  concerned,  from 
that  which  would  be  advised  if  the  case  were  independent  of  the  influ- 
enza bacillus.  The  case,  as  a  whole,  however,  will  require  closer  watch- 
ing, and  on  account  of  the  greater  prostration,  better  feeding  and  freer 
stimulation. 

The  hard,  dry,  teasing,  tracheal  cough  associated  with  and  following 
many  cases  of  influenza,  is  sufficiently  troublesome  to  require  special 
mention.  In  this  condition  codein  should  be  used  in  sufficient  dosage 
partially  to  control  the  cough.  The  cough  is  difficult  to  relieve  for  the 
reason  that  the  mucous  membrane  of  the  trachea  is  deeply  congested. 
The  infection,  aided  by  the  persistent  cough,  keeps  up  and  adds  to  the 
congestion;  and  the  irritation  thus  produced  again  tends  to  a  persis- 


SYPHILIS  677 

tence  of  the  cough.  This  is  a  condition  where  opium  is  not  only  justi- 
fiable, but  absolutely  necessary,  in  order  that  sufficient  rest  of  the  parts 
may  be  secured  to  allow  resolution  and  control  of  the  infection. 

yapor. —Charging  the  air  with  vapor,  producing  an  artificial  hu- 
midity, greatly  lessens  the  irritating  efTects  on  the  mucous  mem- 
brane of  the  ordinarily  dry  air  of  the  hving  room,  and  relieves  the 
cough. 

External  Treatment. — A  preparation  of  mustard, — one  part  flour  to 
two  parts  mustard, — suitably  mixed  and  applied  to  the  chest  for  five 
to  fifteen  minutes  at  bed-time,  will  often  insure  a  better  night  than 
would  result  were  the  application  not  made. 

Change  of  Climate. — When  possible,  patients  who  show  pronounced 
systemic  depression  and  who  fail  to  regain  their  usual  physical  vigor 
should  have  the  benefit  of  a  change  of  climate.  A  change  of  a  few 
weeks  will  ordinarily  completely  restore  the  patient  to  his  normal 
health.  When  at  home,  or  elsewhere,  convalescent  grip  patients  who 
show  slow  response  to  treatment  should  have  their  activities  carefully 
advised;  they  should  not  be  ahowed  to  arise  before  10  in  the  morning, 
should  have  a  midday  rest  of  two  hours,  and  should  retire  between  6 
and  7  o'clock. 

Drugs. — Small  doses  of  quinin,  one  to  two  grains  at  two-  or  three- 
hour  intervals,  have  given  better  results  in  hastening  a  return  to  health 
than  any  other  form  of  medication.  If  there  are  malnutrition  and 
anemia,  the  measures  laid  down  under  the  respective  headings  may  be 
applicable  to  these  patients. 

SYPHILIS 

Syphilis  is  an  infectious,  communicable  disease  seen  with  great  fre- 
quency in  early  life  in  all  large  centers  of  population. 

In  1905  Schaudinn  and  Hoffmann  discovered  a  spirochete  in  syphi- 
litic lesions.  From  its  faint  staining  reaction  they  named  the  organ- 
ism Spirochseta  pallida,  and  later  Treponema  pallidum.  It  is  present 
in  syphilitic  lesions  on  the  skin  and  mucous  membrane,  and  has  been 
found  in  the  blood,  in  the  internal  organs,  in  the  lymph-nodes,  in 
spermatozoa,  in  ova,  and  in  cerebrospinal  fluid  of  syphilitic  patients. 
The  tissues  and  organs  of  still-born  syphilitic  infants  contain  the 
spirochete,  and  in  congenitally  syphilitic  children  the  organism  is 
readily  demonstrable  in  the  mucous  patches  in  the  mouth,  in  the  fis- 
sures about  the  mouth  and  anus,  and  in  the  skin  lesions.  The  older 
the  lesion,  the  less  numerous  are  the  spirochetes. 

Noguchi  was  the  first  investigator  who  succeeded  in  obtaining  pure 
cultures  of  Treponema  pallidum,  and  by  inoculating  such  pure  stains 
into  rabbits  he  has  produced  syphilis  in  these  animals.  There  can  no 
longer  be  any  doubt  of  the  etiologic  relationship  between  Treponema 
pallidum  and  syphilis.  The  spirochete  is  mobile,  varying  in  length 
and  thickness,  its  average  transverse  diameter  being  0.2  to  0.3  micron. 
It  is  best  seen  in  the  fresh  state,  with  the  dark  field  illumination.  A 
rough  but  fairly  reliable  method  of  demonstrating  the  spirochete  is  to 


678  THE    PRACTICE    OF    PEDIATRICS 

mix  the  material  to  be  examined  on  a  slide  with  a  drop  of  India  ink. 
By  means  of  a  piece  of  cigarette  paper  the  mixture  is  easily  spread 
evenly  along  the  slide.  Examination  with  the  immersion  lens  shows 
the  unstained  spirochetes  on  a  black  background. 

The  disease  in  children  is  usually  due  to  direct  inheritance,  although 
acquired  cases  are  occasionally  encountered.  We  have  accordingly 
to  consider  both  the  hereditary  and  the  acquired  types.     (See  p.  685.) 

For  convenience  of  description  hereditary  cases  are  discussed  under 
two  headings:  Acute  hereditary  or  congenital  and  later  or  tardy  syphilis. 

Acute  Hereditary  or  Congenital  Syphilis 

The  severity  of  the  infection  in  the  offspring  bears  a  distinct  rela- 
tionship to  the  severity  and  recentness  of  the  infection  in  the  parent  or 
parents.  As  in  all  infections,  the  disease  may  be  most  severe,  or  mild 
to  such  a  degree  that  its  existence  is  not  recognized.  A  recent  infec- 
tion in  either  parent,  or  in  both,  produces  the  most  active  manifesta- 
tions, many  times  sufficient  to  destroy  the  life  of  the  fetus  or  even  to 
preclude  pregnancy.  Death  of  the  fetus,  showing  marked  syphilis, 
any  time  before  the  ninth  month  indicates  a  comparatively  recent 
infection  in  the  parents.  It  is  the  parents  in  whom  the  disease  is  of 
long  duration  or  who  have  undergone  active  treatment  who  are  respon- 
sible for  the  tardy  hereditary  form. 

Symptoms. — The  symptoms,  which  are  most  variable,  depend 
upon  the  age  of  the  patient  and  the  severity  of  the  infection. 

Thus  the  child  may  be  born  dead  at  term.  I  have  repeatedly  seen 
these  infants  almost  denuded  of  skin  and  showing  bone  and  extensive 
visceral  lesions. 

In  other  instances  the  child  is  born  at  term,  alive,  but  shows  syphi- 
litic pemphigus  and  other  lesions,  and  lives  but  a  few  hours.  Other 
infants  are  born  apparently  normal  and  show  signs  of  the  disease  be- 
fore the  sixth  week.  Symptoms  are  very  apt  to  appear  between  the 
second  and  fourth  weeks.  Seventy-five  per  cent,  of  my  cases  have 
shown  diagnostic  signs  before  the  fourth  month.  Some  cases  do  not 
show  signs  until  a  later  period — the  sixth,  seventh,  or  eighth  month. 
Such  cases,  however,  are  unusual.  The  great  majority  show  some 
active  evidence  of  the  disease  before  the  sixth  month.  The  first 
manifestation  in  congenital  syphilis  may  appear  at  any  time  up  to  the 
thirtieth  year  (Fournier). 

In  infants  apparently  normal  at  birth  and  developing  the  signs  early 
the  symptoms  are  as  follows: 

(1)  Restlessness. 

(2)  Rhinitis;  hoarse  voice. 

(3)  Enlarged  liver  and  spleen. 

(4)  Rash;  condylomata;  mucous  patches. 

(5)  Enlargement  of  epitrochlear  glands. 

(6)  Deformities  of  the  nails. 

(7)  Defective  growth  and  malnutrition. 


SYPHILIS 


679 


Restlessness  is  the  earliest  symptom  of  syphilis.  The  child  sleeps 
poorly  and  is  uncomfortable.  This  symptom  is  many  times  not  appre- 
ciated by  the  physician  and  usually  passes  unrecognized  by  the  parents. 
The  restlessness  is  usually  attributed  to  causes  other  than  syphihs. 


Fig.  96. — Rash  in  congenital  syphilis. 

Rhinitis  is  a  very  early  symptom,  and  one  that  is  seldom  absent. 
It  is  characterized  particularly  by  its  persistence  and  the  profuseness 
of  the  discharge;  in  other  respects  it  may  not  vary  from  an  ordinary 
rhinitis. 


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Fig.  97. — Condylomata. 

In  a  considerable  proportion  of  these  cases  there  is  a  moderate  de- 
gree of  laryngitis  with  hoarseness.  I  have  seen  cases  in  which  this  sign 
was  the  earliest  and  most  prominent  symptom. 


680 


THE    PRACTICE    OF    PEDIATRICS 


Liver  and  Spleen. — An  enlargement  of  the  liver  and  spleen  is  an 
early  sign  in  most  cases.  The  spleen  will  be  palpable  below  the  rib  for 
3^  to  2  inches.     The  liver  also  shows  enlargement,  often  extending  2 

to  3  inches  below  the  free 
border  of  the  rib. 

The  Rash. — The  rash 
may  appear  very  early  or 
may  be  delayed  for  a  week 
or  longer  after  the  rhinitis. 
The  rash  is  fairly  charac- 
teristic. It  appears  in  dis- 
crete, brownish  -colored 
macules  (Fig.  96),  rounded 
and  with  a  tendency  to  a 
very  fine  desquamation  in 
the  center.  The  skin  be- 
tween the  macules  may 
remain  normal.  The  ma- 
cules may  occur  in  groups 
and  become  so  extensive 
as  to  coalesce  and  involve 
a  large  part  of  the  skin  sur- 

„         .  ,.,.,.        ,  faceof  the  patient  (Fig.  98). 

Fig.  98.-Extensive  syphilitic  rash.  ^^^  ^^.^^  p^^^^  ^^^^^ 

the  buttocks,  legs,  and  over  the  abdomen  are  usually  involved  first 
and  most  extensively.  There  is  no  order,  however,  as  to  the  appear- 
ance of  the  rash,  the  face  and  the  arms  may  be  first  affected,  or  the 
rash  may  be  generally  distributed  over  the  entire  skin  surface.     When 


Fig.  99. — Fissures  and  mucous  patches. 

the  rash  fades,  the  skin  becomes  smooth,  but  there  is  left  a  copper- 
colored  stain  which  is  as  characteristic  of  the  disease  as  the  rash. 
When  the  eruption  occurs  about  the  anus  or  the  moist  parts,  as  in 


SYPHILIS  681 

flexures  and  skin  folds,  the  eruption  sloughs  and  condylomata  are 
formed  (Fig.  97). 

In  many  cases,  particularly  in  very  young  infants,  a  diffuse  thicken- 
ing of  the  skin  of  the  soles  of  the  feet  and  palms  of  the  hands  occurs 
with  profuse  desquamation  (Fig.  100),  leaving  the  skin  of  a  glossy, 
shining  appearance.  How  long  the  skin  eruption  would  continue  un- 
treated if  the  patient  survived  is  difficult  to  determine.  Under  suit- 
able medication  the  eruption  largely  disappears  in  two  to  four  weeks, 
leaving  the  copper-colored  disfigurations,  which  in  turn  fade,  but 
require  a  much  longer  time  (Fig,  98) . 

Fissures  at  the  angles  of  the  mouth  and  on  the  lip  and  mucous 
patches  (Fig.  99)  are  really  a  part  of  the  skin  manifestations — they  are 
characteristic  in  the  sense  that  they  occur  only  in  syphilis.  A  mucous 
patch  represents  the  site  of  papule  or  macule  on  a  moist  surface.     Such 

" 1 


Fig.  100. — Desquamation.     Soles  of  feet.     Congenital  syphilis. 

lesions  are  usually  found  on  the  mucous  membrane  of  the  mouth. 
Other  possible  sites  are  the  anus  and  the  female  genitals. 

Acute  epiphysitis  occurs  in  young  infants,  but  in  this  country  it  is 
an  unusual  manifestation  of  syphilis.  There  is  swelling  of  the  epiphy- 
seal cartilages  and  there  may  be  separation  of  the  epiphysis.  The  parts 
are  very  painful,  giving  rise  to' the  term  "syphilitic  pseudoparalysis." 

The  Nails. — The  nails  are  dwarfed,  dry,  and  break  readily.  There 
may  be  exfoliation  of  the  nail,  but  this  is  unusual  in  infants.  A  char- 
acteristic deformity  is  the  bird-claw  nail,  in  which  the  nail  is  much 
contracted,  showing  an  arching  of  the  dorsum  of  the  nail  with  thicken- 
ing, and  a  downward  curve  at  the  free  end,  over  the  tip  of  the  finger 
or  toe,  producing  a  typical  claw  appearance.  This  is  a  symptom  of 
much  diagnostic  value. 

Hemorrhage. — Hemorrhages  in  congenital  syphilis  are  rare.  They 
may  occur  from  any  mucous  surface.  In  a  large  number  of  cases  of 
congenital  syphilis  seen  in  this  country  and  on  the  continent  there  were 


682  THE    PRACTICE    OF    PEDIATRICS 

but  two  in  which  hemorrhage  was  a  symptom.     In  both  these  cases, 
strange  to  say,  there  was  quite  severe  hemorrhage  from  the  vagina. 

Treatment. — Mercurial  Treatment. — Until  recently  the  only  means 
of  treating  congenital  syphilis  in  infants  was  by  the  use  of  mercury, 
locally,  as  by  inunctions,  or  by  internal  administration.  The  use  of 
mercurial  ointment  by  inunction  is  a  satisfactory  method  in  hospitals 
and  in  children's  institutions,  where  a  nurse  can  make  the  necessary 
applications;  in  private  practice,  however,  it  is  objectionable  because 
of  the  inunction  itself,  which  may  cause  comment,  and  because  of  the 
staining  of  the  skin.  In  fact,  this  treatment  cannot  well  be  carried  on 
without  other  members  of  the  family  becoming  acquainted  with  the 
nature  of  the  illness.  Definite  rules  for  management,  as  regards  kissing 
and  the  care  of  feeding  utensils,  should  be  given,  so  that  the  other  mem- 
bers of  the  family  may  be  protected  and  the  real  condition  remain 
unknown.  Among  the  poorer  class,  and  in  outpatient  work,  I  have 
found  the  inunction  method  unsatisfactory,  for  the  additional  reason 
that  its  use  is  not  continued  sufficiently,  and  it  is  very  apt  to  be  indif- 
ferently done.  It  is  often  postponed  and  forgotten.  As  the  disease 
permits  of  no  temporizing,  it  is  for  the  interest  of  the  patient  that  the 
most  effective  jneans  possible  for  its  control  be  brought  into  use  at  the 
earliest  possible  moment;  this  is  by  the  internal  administration  of 
mercury. 

If  the  inunction  is  employed,  the  mercurial  ointment,  U.  S.  P., 
should  be  used,  10  grains  being  rubbed  into  the  skin  daily.  The  rub- 
bing should  be  continued  about  ten  minutes,  as  this  time  will  be  re- 
quired for  the  ointment  to  be  thoroughly  absorbed. 

Bichlorid  Hypodermically  Administered. — Veeder  of  St.  Louis  in  a 
private  communication  states  that  the  bichlorid  of  mercury  adminis- 
tered hypodermically  is  quite  comparable  in  rapidity  of  results  to 
salvarsan.  A  1  per  cent,  solution  of  bichlorid  is  used.  In  runabouts 
and  older  children  Veeder  injects  from  10  to  20  minims  every  other  day 
for  six  injections,  then  rests  for  a  week  and  repeats  the  course.  The 
injection  is  given  into  the  muscles  of  the  buttocks.  In  young  infants 
the  dosage  is  3  minims. 

Frequent  examination  of  the  urine  is  necessary  during  this  treat- 
ment because  of  the  possible  development  of  nephritis. 

The  Internal  Use  of  Mercury. — The  use  of  mercury  internally  gives 
the  best  results  among  all  classes.  It  is  my  observation,  after  the 
treatment  of  several  hundred  of  these  cases,  that  the  bichlorid  of  mer- 
cury in  small,  frequently  repeated  doses  is  the  best  form  of  medication. 
It  is  given  in  tablet  form.  Its  use  may  have  to  be  continued  for  a  long 
time,  and,  as  people  are  fond  of  giving  drugs,  we  cater  to  the  weak  side 
of  human  nature,  and  thus  do  the  greatest  good  to  our  patient. 

The  Dosage  and  Method  of  Administration. — For  all  infants  under 
one  year  of  age  the  scheme  of  medication  is  the  same,  and  this  covers 
the  great  majority  of  our  cases.  Usually  the  patient  is  seen  before  the 
third  month.  I  order  the  tablet  triturate  of  bichlorid  of  mercury,  3^^oo 
grain.     The  mother  is  instructed  to  give  two  tablets  daily,  morning 


SYPHILIS  683 

and  night,  after  feeding.  She  is  told  to  give  on  alternate  days  an 
additional  tablet  after  feeding,  until  five  are  given  daily,  or  until  the 
mercury  produces  loose  green  stools.  It  is  comparatively  rare  that  an 
infant  of  the  tenderest  age  cannot  take  3^o  grain  daily  without  incon- 
•  venience.  If  green  stools  of  a  watery  character  result,  the  increase  is 
temporarily  withheld.  It  is  very  rare  that  the  above  amount  will  not 
ultimately  be  taken  without  inconvenience.  Further,  the  dosage  of 
3^0  to  }-^o  grain  in  twenty-four  hours,  in  the  great  majority  of  the  cases, 
is  all  that  is  necessary  to  control  the  disease.  If  an  improvement  does 
not  take  place  after  a  week's  administration,  in  the  absence  of  intestinal 
symptoms,  the  amount  may  be  increased  to  3'^o  grain  in  twenty-four 
hours. 

If,  after  the  administration  four  or  five  times  daily  of  the  bichlorid 
in  the  small  doses  of  )-^oo  grain  has  been  continued  for  several  days,  im- 
provement does  not  take  place  because  of  failure  on  the  part  of  the 
child  to  absorb  the  drug,  inunctions  may  be  used  in  addition  to  the 
internal  treatment.  This  has  been  necessary,  however,  in  but  few  of 
my  cases. 

Convalescence. — In  a  typical  case  the  first  sign  that  the  child  is  im- 
proving will  be  the  fading  of  the  rash.  It  disappears  gradually,  leaving 
the  characteristic  staining  of  the  skin,  which  also  clears  up  in  a  few 
weeks.  Coincident  with  the  fading  of  the  rash,  the  coryza  becomes  less 
pronounced  and  the  hoarse  voice  becomes  clearer.  If  there  has  been 
an  enlargement  of  the  liver  and  spleen,  after  a  few  weeks  of  treatment 
they  will  be  noticed  to  have  diminished  in  size.  The  child  gains  in 
weight,  and  if  the  case  progresses  satisfactorily,  soon  looks  like  a  normal 
baby.  This,  however,  is  not  always  the  happy  outcome.  Occasion- 
ally we  have  patients  with  the  vital  powers  greatly  depressed  or  with  so 
intense  an  infection  that  treatment  is  of  no  avail,  and  they  die  in  a  few 
weeks  from  marasmus.  In  such  cases  and  in  all  instances  of  very 
severe  infection  salvarsan  should  be  given  with  mercury.  The  action 
of  the  salvarsan  is  very  prompt  and  will  check  the  progress  of  the 
disease  much  sooner  than  mercury,  regardless  of  its  method  of 
administration. 

The  enlargement  of  the  epitrochlear  glands  is,  in  my  experience,  the 
last  sign  to  disappear,  and  in  many  cases  these  glands,  though  reduced 
in  size,  always  remain  enlarged  without  any  other  persistent  evidence 
of  the  disease.  A  patient  is  considered  cured  who  fails  to  give  a  posi- 
tive reaction  to  repeated  tests  of  the  blood,  according  to  the  Wasser- 
mann  method. 

Later  Treatment. — What  should  be  the  further  management  of  such 
a  so-called  "cured"  case?  Are  we  justified  in  discharging  the  patient 
and  allowing  him  to  pass  from  our  observation?  My  experience  proves 
the  contrary,  nor  can  I  state  that  congenital  syphilis  is  ever  cured.  I 
have  seen  many  patients,  however,  who  were  apparenth^  cured,  and  who 
showed  no  signs  whatsoever  of  the  disease.  Against  my  advice  they 
have  passed  from  observation  for  two,  three,  or  four  j^ears,  and  then 
have  reappeared  for  treatment,  because  of  the  presentation  of  some 


684  THE    PRACTICE    OF    PEDIATRICS 

manifestation  of  a  tertiary  character — a  so-called  "tardy  hereditary 
syphiUs."  For  this  reason  I  believe  every  so-called  cured  congenital 
case  should  be  subjected  to  the  Wassermann  test  every  two  years  or 
oftener. 

The  Arsenicals  in  the  Treatment  of  Hereditary  Syphilis. — In  chil- 
dren, neosalvarsan  is  now  used  almost  to  the  exclusion  of  salvarsan. 
The  technic  is  much  less  complicated,  leakage  into  the  tissues  much 
less  serious  and  the  untoward  by-effects  ascribed  to  salvarsan  are  never 
seen.  However,  the  effect  of  the  neosalvarsan  is  not  so  spectacular 
nor  so  lasting  as  that  of  salvarsan. 

The  greatest  value  of  the  arsenicals  is  in  the  very  severe  congenital 
case.  Repeatedly  I  have  seen  these  infants  die  before  the  effects  of 
mercury  could  be  manifested.  The  arsenicals  act  much  more  rapidly 
than  mercury.  In  fact,  the  results  of  salvarsan  treatment  on  the  very 
severe  congenital  syphilitic  borders  on  the  miraculous. 

The  chief  value  of  salvarsan  in  pediatric  work  is  in  this  type  of 
case:  for  permanent,  beneficial  effects  we  are  still  dependent  upon 
mercury  and  the  iodids. 

Dosage. — For  babies  under  six  months,  the  average  dose  of  neo- 
salvarsan is  0.075  gm.  to  0.2  gm.  and  for  older  children  0.2  gm.  to 
0.4  gm.  Salvarsan  is  used  in  doses  one-half  as  large.  The  consensus 
of  opinion  now  seems  to  be  that  the  arsenical  should  be  given  at  weekly 
intervals  until  the  gross  lesions  have  cleared  up.  This  is  always 
followed  by  the  use  of  mercury.  The  arsenicals  do  not  effect  a  cure 
alone. 

Technic. — The  technic  advised  by  Holt  and  Brown*  and  carried 
out  at  the  Babies'  Hospital  is  as  follows: 

The  patient  is  tightly  wrapped  in  a  sheet  to  secure  the  hands  to  the 
sides  in  order  to  prevent  struggling.  The  child  is  then  placed  on  the 
table  with  the  head  hyperextended  and  turned  to  whatever  side  is 
desired  and  held  in  this  position  by  an  assistant.  By  this  method, 
introduction  of  the  needle  of  a  glass  luer  syringe  is  readily  effected 
into  either  of  the  auricular  veins  during  a  paroxysm  of  crying.  The 
scalp  veins  are  chosen  because  of  the  fact  that  they  lie  more  superfi- 
cially and  are  more  firmly  bound  by  connective  tissue,  thus  facilitating 
the  introduction  of  the  needle.  The  external  jugular  veins  may  be 
used  in  a  similar  manner. 

The  mode  of  treatment  by  the  injection  of  salvarsan  into  the  supe- 
rior longitudinal  sinus  is  a  safe  and  easy  method  of  intravenous  injec- 
tion in  infants.  In  the  average  new-born  infant,  the  sinus  at  the  pos- 
terior angle  of  the  fontanelle  is  about  one-quarter  of  an  inch  wide;  in 
the  sagittal  suture  one  and  a  half  inches  behind  the  fontanelle,  it  is 
about  five-sixteenths  of  an  inch.  The  latter  position  is  the  better 
choice,  as  long  as  the  suture  remains  open.  A  20  c.c.  glass  luer  syringe 
with  an  18  or  20  gage  needle  with  a  sharp  bevel  (about  45  degrees)  is 
used.     The  needle  has  a  furrow  filed  in  it  about  five-sixteenths  of  an 

*  Amer.  Journal  Diseases  of  Children,  Sept.,  1913. 


SYPHILIS  685 

inch  from  the  tip.  A  silk  thread  is  tied  in  the  furrow  and  then  wound 
a  few  times  about  the  needle  above  the  groove  and  tied  again.  This 
acts  as  a  guard  to  prevent  the  needle  sinking  too  deeply  into  the  sinus. 
The  infant  is  held  firmly  on  its  back  with  the  head  shghtly  flexed. 
The  needle  is  passed  into  the  sinus  from  before  backward  with  the 
bevel  of  the  needle  parallel  with  the  skin,  so  that  the  opening  in  the 
needle  is  patent  as  soon  as  it  enters  the  sinus.  If  the  infant  be  crying 
the  blood  is  usually  forced  up  into  the  syringe  if  the  piston  be  not  held 
too  firmly;  otherwise  the  blood  is  drawn  into  the  syringe  to  prove  that 
the  needle  is  within  the  sinus  before  the  salvarsan  is  injected.  Autopsy 
findings  in  cases  in  which  the  needle  has  passed  through  the  sinus 
revealed  no  evidence  of  injury  to  the  sinus  or  the  presence  of  blood 
about  the  sinus. 

Diarsenol  and  arsenobenzol  are  excellent  substitutes  for  neosal- 
varsan  but  offer  the  same  dangers  as  salvarsan.  These  drugs,  because 
of  patent  rights,  cannot  be  made  after  the  war  in  Europe.  The  dosage 
is  the  same  as  neosalvarsan. 


Acquired  Syphilis 

Acquired  syphiKs  in  children,  in  my  observation,  is  a  comparatively 
rare  occurrence.  The  mouth  is  the.  most  frequent  site  for  the  primary 
lesion,  the  genitals  being  rarely  involved.  Infection  may  be  conveyed 
by  direct  contact,  as  in  kissing  or  by  sexual  contact.  The  virus  may 
be  conveyed  by  intermediaries,  such  as  toys,  nipples,  and  feeding 
utensils. 

The  recital  of  statistics  and  special  modes  of  infection  adds  nothing 
to  our  knowledge  of  the  subject.  It  is  necessary  to  remember  that  a 
localized  lesion,  sUghtly  sloughing  over  its  surface,  indurated  and 
sharply  defined,  may  be  in  a  child  the  initial  lesion  of  syphilis. 

The  treatment  is  the  same  as  that  of  the  hereditary  form. 

Tardy  Hereditary  Syphilis 

In  this  form  of  syphilis  the  chief  or  only  manifestation  of  the  disease 
occurs  at  a  later  period  of  life.  Fournier  states  that  the  first  signs  of 
the  disease  may  appear  as  late  as  the  thirtieth  year.  That  the  case  in 
which  positive  signs  are  not  observed  until  after  the  third  year  did  not 
show  unrecognized  signs  early  in  life  is  an  open  question.  Judging 
from  my  own  patients,  and  what  could  be  learned  about  their  early  life 
from  intelligent  mothers  or  attendants,  I  am  convinced  that  an  indi- 
vidual may  show  signs  of  syphilis  at  varying  periods  after  infancy  with- 
out early  signs  of  the  disease.  Several  years  ago  I  reported  six  cases 
of  tardy  malnutrition  of  syphilitic  origin  in  which  there  had  been  no 
early  signs  of  the  disease.  Since  that  time  I  have  seen  several  other 
cases  of  a  similar  nature. 

The  great  majority  of  my  patients  with  tardy  hereditary  syphilis 


686  THE    PRACTICE    OF    PEDIATRICS 

however,  are  those  who  were  treated  in  outpatient  cUnics  or  elsewhere 
and  who  discontinued  treatment  when  the  active  symptoms  were  re- 
lieved. I  have  had  such  experience  with  my  own  outpatients  and 
have  treated  similar  cases  from  other  outdoor  services.  Many  mothers 
cannot  be  made  to  bring  their  children  for  treatment  and  observation 
when  the}^  are  apparently  well. 

Pathology. — 1.  Eye. — The  eye  changes  are  those  of  an  interstitial 
keratitis,  gummatous  involvement  of  the  iris,  and  the  so-called  deep 
inflammations  of  the  eye,  chorioretinitis  and  optic  neuritis. 

2.  Ear. — Progressive  deafness  due  to  neuritis  acustica  (Meniere's 
disease) . 

3.  Skin. — According  to  Fochsinger,  the  changes  in  the  skin  do  not 
differ  from  the  tertiary  skin  lesions  of  acquired  syphilis.  He  described 
two  forms,  first,  small  nodules,  and,  second,  large  nodular  late  syphilids. 
The  small  nodules  are  due  to  a  definite  infiltration  of  the  true  skin, 
which  presents  a  brownish  appearance  and  may  desquamate  or  become 
covered  with  a  heavy  crust.  Beneath  the  crusts  there  is  usually  broken 
down  granular  tissue.  The  large  nodular  syphilid  occurs  in  the  form 
of  large  skin  gummata  and  gummatous  ulcers  arising  from  the  sub- 
cutaneous tissues. 

4.  Mucous  Membrane  of  the  Respiratory  Tract. — This  structure  may 
become  invaded  in  a  specific  manner.  It  may  be  the  seat  of  gumma- 
tous infiltrations  or  a  rapidly  progressive  ulceration.  Ulcerations  of  the 
pharynx  and  larynx  are  not  rare.  Such  lesions  are  usually  character- 
ized by  definitely  defined  borders  and  thick  indurated  walls.  In  the 
nose  there  may  be  a  diffuse  osseous  and  periosteal  affection  of  the  entire 
nasal  skeleton,  or  a  gummatous  change  may  represent  the  primary 
pathologic  process,  followed  by  ulceration  with  much  pus  and  crust 
formation.  On  the  contrary,  there  may  occur  an  atrophic  condition 
of  the  mucous  membrane.  Levin  and  Heller  describe  a  smooth  atro- 
phy of  the  base  of  the  tongue  characterized  by  absence  of  glandular 
tissue  and  thinness  of  the  mucous  membrane.  Gummatous  formation, 
as  described  above,  may  occur  on  the  velum  palati,  palatine  arches, 
and  uvulae,  with  perforation.  All  the  ulcerations  which  take  place 
show  a  great  tendency  to  scar  formation,  with  corresponding  contrac- 
tions and  adhesions  to  their  adjacent  parts. 

5.  Lymph-nodes. — A  general  hyperplasia  of  the  lymphatic  tissue  of 
the  pharynx  and  nasopharynx,  including  the  tonsils,  may  take  place, 
while  in  the  lymph-nodes  throughout  the  body,  aside  from  general  hy- 
perplasia, gummatous  formation  is  not  uncommon.  Occasionally  the 
glands  may  undergo  ulceration. 

6.  Vessels. — There  may  exist,  according  to  Hochsinger,  a  gumma- 
tous aortitis,  arteriosclerosis,  and  phlebosclerosis,  while  myocardial  and 
endocardial  changes  have  been  observed. 

7.  Viscera. — Liver  affections  deserve  the  first  rank.  There  may 
exist  large  nodular  gummata;  the  diffuse  hypertrophic  cirrhosis  is  most 
common.  These  changes  are  almost  always  associated  with  more  or 
less  splenic  hypertrophy.     The  kidneys  may  be  small  and  contracted; 


SYPHILIS 


687 


amyloid  degeneration  is  rare.     Gummatous  formation  in  the  lungs 
may  occur,  but  it  is  very  uncommon. 

8.  Bones. — Late  syphilitic  changes  occur  in  the  osseous  system 
either  as  a  diffuse  hyperplastic  ostitis  and  periostitis,  or  as  a  gumma- 
tous process;  lesions  of  both  varieties,  however,  may  occur  at  the  same 
time  in  the  one  individual.  According  to  Lannelongue,  a  hyperplastic 
ostitis  and  periostitis  may  involve  the  whole  skeleton.  The  long  bones 
are  chiefly  affected.  The  same  author  considers  that  the  so-called 
Paget's  bone  disease,  which  is  a  diffuse  progressive  periostitis  leading 
to  hyperostosis,  is 
nothing  more  nor  less 
than  hereditary 
syphilis. 

The  tibia  is  the 
bone  most  frequently 
involved.  The  disease 
here  produces  what  is 
known  as  the  ''saber 
deformity."  (See  Fig 
101.)  Following  the 
hyperplastic  stage  is 
the  real  stage  of  hyper- 
ostosis, the  deformity 
being  due  to  the  con- 
tinuous formation  of 
new  periosteal  bone 
layers  about  the 
primary  one. 

Among  the  less  fre- 
quent bone  changes  in 
late  hereditary  syphilis 
is  a  rarefying  periostitis 
leading  to  bone  absorp- 
tion. This  condition 
is  seen  on  the  surface 

of  the  cranial  bones  and  causes  the  formation  of  rough  areas  (caries 
sicca) . 

Joint  affections  may  occur  in  late  hereditary  syphihs  in  the  form  of 
a  simple  hydrops  without  capsular  thickening  or  a  hyperplastic  syno- 
vitis. Again  there  may  be  a  combination  of  hydrarthrosis,  with 
swelling  of  the  joint-ends  of  the  hollow  bones,  and  in  rare  instances  a 
condition  resembling  white  swelling. 

Symptoms. — This  form  of  syphiUs  in  the  young  may  manifest  itself 
in  widely  different  ways. 

Errors  in  Nutrition  (see  p.  689). — A  not  infrequent  manifestation 
is  that  of  moderate  malnutrition  and  stunted  growth.  The  patient  is 
habitually  pale,  undersized,  and  shows  lack  of  resistance,  and  such 
evidences  may  be  the  only  signs  of  the  disease. 


Fig.  101. — Showing  saber  deformity  of  legs  in 
tertiary  congenital  syphilis  in  a  child  nine  years 
of  age   (Dr.  Sill). 


688 


THE    PRACTICE    OF    PEDIATRICS 


The  Bones. — Characteristic  signs  are  to  be  found  in  the  bones  and 
teeth.  The  shafts  of  the  long  bones  are  involved  in  a  periostitis.  (See 
Fig.  101.)  The  tibia  when  affected  may  show  the  saber  deformity. 
The  tibise  are  most  frequently  involved;  next  in  frequency,  the  radii. 
Gummata  may  involve  the  flat  bones  of  the  cranium,  although  such  an 
occurrence  is  comparatively  rare.  The  "saddle  nose"  caused  by  a 
destruction  of  the  septum  is  a  condition  not  infrequently  seen  in  con- 
genital syphilis. 

The  T eeth.^F Qxdy  characteristic  signs,  first  described  by  Hutchin- 
son, are  often  shown  by  the  second  set  of  teeth.  The  first  set  in  no  way 
give  evidence  of  the  disease.  Hutchinson's  teeth  represent  faulty  de- 
velopment. They  are  variously  described,  according  to  the  deformity 
presented,  as  notched,  "screw-driver,"  and  peg-shaped.  (See  Fig. 
102.) 


Hutchinson  teeth. 


Lymph-nodes. — The  only  lymph-node  involvement  of  significance 
is  that  of  the  epitrochlears.  General  lymph-node  involvement  is  to 
be  looked  upon  as  corroborative  of  other  signs  of  consequence. 

The  Eye. — A  diffuse  interstitial  keratitis  is  one  of  the  most  frequent 
manifestations  of  tardy  hereditary  syphilis. 

Involvement  of  Other  Structures  and  Organs. — The  spleen  is  usually 
enlarged,  the  liver  not  infrequently.  I  have  seen  three  cases  of  brain 
tumor  of  syphilitic  origin.  As  is  well  known,  any  portion  of  the  body 
may  be  involved  in  a  syphilitic  process,  and  a  detailed  description  of 
the  various  possibilities  is  out  of  place  at  this  time.  The  symptoms  as 
outlined  represent  the  usual  manifestations. 

Treatment. — My  experience  with  salvarsan  in  tardy  hereditary 
syphilis  has  been  thoroughly  unsatisfactory.  As  in  the  treatment 
of  tertiary  syphilis  in  the  adult,  likewise  in  the  treatment  of  the 
late  hereditary  form  in  children,  the  iodids  play  an  important  part. 


SYPHILIS  689 

Much  better  results,  however,  are  obtained  with  the  so-called 
"mixed  treatment."  The  iodids  alone  are  not  sufficient  to  give 
us  our  best  results,  and  the  results  with  mercury  alone  are 
not  so  prompt  and  satisfactory  as  when  the  two  drugs  are 
combined.  For  an  average  case  of  periostitis  involving  the  an- 
terior portion  of  the  tibia  in  a  child  four  years  of  age,  from  3^o  to 
3-^0  grain  of  bichlorid  of  mercury  should  be  given  daily,  combined  with 
suflEicient  iodid  of  potash  to  produce  the  characteristic  coryza.  This 
may  necessitate  the  giving  of  from  12  to  20  grains  of  iodid  daily,  as 
children  vary  greatly  in  their  susceptibility  to  the  drug.  The  mercury 
and  the  iodid  of  potash  should  not  be  given  in  one  mixture,  as  the  com- 
bination is  most  disagreeable  to  the  taste.  It  is  far  better  to  give  the 
bichlorid  in  the  form  of  tablet  triturates.  The  iodid  of  potash  is  best 
given  in  a  saturated  solution,  one  drop  of  which  represents  one  grain 
of  the  drug.  This  is  best  taken  when  dropped  into  milk  after  meals. 
Beneficial  results  from  the  treatment  will  usually  be  apparent  in  a  few 
days.  If  there  is  a  periostitis,  the  pain  will  be  the  first  symptom  to 
disappear. 

The  administration  of  the  iodid  of  potash  should  always  be  inter- 
rupted, chiefly  because  of  the  possibilities  of  deranging  the  child's  di- 
gestion. I  usually  give  the  drug  for  ten  days,  followed  by  a  rest  of  five 
days,  when  it  is  again  resumed.  Proper  nutrition  in  these  cases  is  a 
most  important  factor  in  their  management.  If  the  iodid  is  given  to 
the  point  of  tolerance,  its  omission  for  a  few  days  will  not  be  noticed. 
The  mercury  is  given  for  weeks  continuously  in  doses  of  from  ^-qq  to  3'^o 
grain  three  times  a  day,  graduated  according  to  the  age.  Later,  when 
the  progress  of  the  case  shows  that  the  disease  is  under  control,  the  two 
drugs  should  be  given  alternately,  for  ten  days  each.  How  long  this 
treatment  should  be  continued  must  be  determined  by  each  individual 
case.  The  Wassermann  test  in  these  cases  is  of  much  service.  Patients 
who  are  apparently  cured  .should  be  instructed  to  report  to  the  physi- 
cian every  three  months.  I  frequently  advise  a  course  of  treatment  for 
three  or  four  weeks,  two  or  three  times  a  year.  A  sufficient  excuse  for 
such  action  may  be  the  condition  of  the  child,  who  may  show  a  tend- 
ency toward  slow  growth  and  improper  nutrition.  The  patients 
should  be  kept  under  observation  for  years  and  should  be  seen  at  stated 
intervals  until  the  adult  period  is  reached,  when  the  nature  of  the 
trouble  should  be  explained  to  them.  The  disease  from  which  such  a 
child  is  suffering  should  always  be  made  plain  to  parents,  or  at  least  to 
one  of  them,  in  order  that  the  patient  may  not  be  allowed  to  pass  from 
under  medical  observation  in  ignorance  of  his  true  condition. 

Tardy  Malnutrition  of  Syphilitic  Origin, — The  possible  manifesta- 
tions of  syphilis  in  the  young,  as  in  the  adult,  are  many.  The  infection 
may  be  so  severe  as  to  destroy  the  fetus,  or  so  mild  in  its  effects  as  to 
make  recognition  difficult.  Not  the  least  interesting  and  important 
of  the  cases  showing  remote  manifestations  are  those  in  which  late  mal- 
nutrition is  the  only  evidence  of  the  syphilitic  infection.  The  patients 
are  usually  thin,  sometimes  sallow,  sometimes  pale,  with  little  or  no 
adipose  tissue.  They  are  almost  always  undersized  as  regards  height, 
44 


690  THE    PEACTICE    OF    PEDIATRICS 

always  underweight;  the  appetite  is  poor,  and  they  have  but  little 
endurance  and  correspondingly  little  resistance.  Those  seen  by  me 
were  between  three  and  ten  years  of  age.  None  of  the  patients  were 
mentall}'  defective.  When  two  such  children  are  seen  in  a  family  in 
which  both  parents  are  robust,  this  circumstance  is  a  strong  indication 
that  the  children  are  suffering  from  the  results  of  a  remote  syphiUtic 
infection  in  one  of  the  parents.  The  physical  examination  may  show 
notliing  definitely,  and  yet  the  Wassermann  reaction  prove  positive. 

Cases  of  late  malnutrition,  non-syphilitic  in  character,  due  to  poor 
hygiene  and  faulty  feeding,  may  present  symptoms  identical  with  the 
above,  so  that  while  the  two  conditions  cannot  be  differentiated  by  the 
clinical  signs,  there  may  be  sufficient  grounds  for  suspicion  to  warrant 
us  in  questioning  the  father,  whereupon  the  history  of  a  primary  sore 
with  perhaps  secondary  lesions  may  be  elicited.  There  may  have  been 
prolonged  treatment,  with  a  subsidence  of  all  the  symptoms,  and  the 
patient  may  have  been  pronounced  cured  and  told  that  he  might  safely 
marry.  Many  times  have  I  heard  this  story  when  the  evidence  of 
transmission  was  before  me  in  the  form  of  a  typical  case  of  congenital 
syphilis. 

Treatment. — Treatment  of  tardy  malnutrition  of  syphilitic  origin 
by  the  supportive  and  restorative  methods  used  in  the  cases  of  non- 
syphilitic  malnutrition  is  without  avail.  (See  Tardy  Malnutrition, 
p.  100.)  These  patients  require  mercury,  either  alone  or  combined  with 
the  iodids.  To  the  usual  methods  of  treatment  with  iron,  cod-liver 
oil,  baths,  and  massage,  there  will  be  but  little  response,  but  if  bichlorid 
of  mercury  or  the  iodid  of  potash  be  added,  the  case  will  improve. 
The  improvement  is  slow,  to  be  sure,  but  it  is  invariable.  The  child 
should  be  given  the  advantage  of  an  outdoor  life,  with  free  ventilation 
of  the  sleeping-room  at  night.  The  food  should  be  highly  nutritious, 
containing  a  large  amount  of  proteid.  Eggs,  meat,  milk,  and  the  high- 
proteid  cereals,  such  as  oatmeal,  are  the  most  valuable.  The  dried 
legumes, — peas,  beans,  and  lentils,— given  in  the  form  of  purees,  are  a 
valuable  addition  to  the  diet.  Salt  baths  at  bed-time  (p.  780)  during 
the  entire  year,  followed  by  oil  inunctions  during  the  cooler  months,  are 
valuable  in  restoring  a  vigorous  condition.  As  these  children  are  al- 
most always  anemic,  it  may  be  well  to  combine  the  bichlorid  of  mer- 
cury with  nux  vomica  and  quinin.  For  a  child  from  five  to  ten  years 
of  age  the  following  prescription  has  been  used  with  marked  benefit: 

I^     Hydrargyri  bichloridi gr.  ss 

Tincturae  nucis  vomicse gtt.  xc 

Extract!  ferri  pomati gr.  x 

Quininse  bisulphatis •  •  •  •  3  j 

M.  Div.  et  ft.  capsula;  no.  xxx. 

Sig. — One  capsule  after  each  meal. 

This  is  given  for  ten  days,  when  the  bichlorid  of  mercury  in  tablet 
form,  l-^Q  grain  three  times  daily  after  meals,  is  given  for  ten  days. 
During  the  ten  days  when  the  bichlorid  is  given  alone  maltine  and  cod- 
liver  oil  may  be  given — one  dessertspoonful  three  times  a  day  after 


TUBERCULOSIS  691 

meals.  In  these  cases  iodic!  of  potash  is  not  to  be  given  early  in  the 
treatment,  for  the  reason  that  the  appetite  is  usually  poor  or  indifferent , 
and  the  administration  of  the  drug  at  this  time  might  further  decrease 
the  desire  for  food.  The  iodid  of  iron  may  be  used  in  doses  of  10  to  15 
drops,  three  times  daily,  if  the  physician  desires  to  change  the  form  in 
which  the  iron  is  administered. 

Duration  of  Treatment. — Prolonged  treatment  will  usually  be  re- 
quired. These  patients  should  be  kept  under  close  observation  for  at 
least  two  years,  or  until  they  arrive  at  adolescence,  when  they  should 
be  made  acquainted  with  the  nature  of  the  disease.  During  the  entire 
growing  period  the  administration  of  mercury  during  one  month  out 
of  every  three,  or  possibly  every  six,  depending  upon  the  child's  condi- 
tion, will  insure  better  growth  and  a  more  vigorous  development  both 
physically  and  mentally. 

TUBERCULOSIS 

Tuberculosis  is  the  condition  resulting  from  an  invasion  of  the  body 
by  the  tubercle  bacillus. 

Tjrpes  of  the  Infection. — ^There  are  two  types  of  the  bacillus — the 
human  and  the  bovine.  In  132  children  between  the  ages  of  five  and 
sixteen  years  Park  and  Krumweide  found  the  bovine  type  in  33  cases. 
In  20  of  these  there  was  a  tuberculous  cervical  adenitis,  in  7  abdominal 
tuberculosis,  and  in  3  generalized  tuberculosis.  Alimentary  origin  of 
generalized  tuberculosis  was  apparent  in  1,  tuberculosis  of  the  bones 
and  joints  in  1,  and  tuberculosis  of  the  tonsil  in  1. 

Of  220  children  under  five  years  of  age  59  showed  the  bovine  type. 
Of  these,  20  showed  tuberculous  cervical  adenitis;  13,  abdominal  tuber- 
culosis; 10,  generalized  tuberculosis — alimentary  origin;  5,  generaUzed 
tuberculosis;  8,  generalized  tuberculosis  including  meningitis — alimen- 
tary origin;  1,  generalized  tuberculosis  including  meningitis;  2,  tuber- 
culous meningitis. 

The  percentages  of  bovine  infections  were  as  follows: 

Children  Five  to      Children  Under 
Sixteen  Years  Five  Years 

Pulmonary  tuberculosis 0  per  cent.  0  per  cent. 

Tuberculous  adenitis  (cervical) 37  per  cent.  57  per  cent. 

Abdominal  tuberculosis 50  per  cent.  68  per  cent. 

Generalized  tuberculosis 40  per  cent.  26  per  cent. 

Tuberculous  meningitis,  with  or  without  localized 

lesion 0  per  cent.  0  per  cent. 

Tuberculosis  of  bones  and  joints 3  per  cent.  0  per  cent. 

Park  and  Krumweide  conclude  as  follows:  "In  children,  the  bovine 
type  of  tubercle  bacillus  causes  a  marked  percentage  of  the  cases  of 
cervical  adenitis  leading  to  operation,  temporary  disablement,  discom- 
fort, and  disfigurement.  It  causes  a  large  percentage  of  the  rarer  types 
of  alimentary  tuberculosis,  requiring  operative  interference  or  causing 
the  death  of  the  child  directly  or  as  a  contributing  cause  in  other 
diseases. 

"In  young  children  it  becomes  a  menace  to  life  and  causes  from  six 
and  one-third  to  ten  per  cent,  of  the  total  fatalities  from  this  disease." 


692  THE    PRACTICE    OF    PEDIATRICS 

The  bovine  infection  is  largely  limited  to  children,  and  the  fatal 
cases  are  further  limited  to  infants  and  very  young  children. 

A  review  of  the  very  extensive  literature  that  now  exists  on  this 
subject  leads  one  to  the  conclusion  that  about  20  per  cent,  of  the  cases 
of  tuberculosis  in  children  are  of  bovine  origin. 

Avenues  of  Entrance. — Tubercle  bacilli  may  enter  the  body  by 
means  of  the  respiratory  and  alimentary  tracts,  by  means  of  the  genito- 
urinary system,  and  through  the  skin.  The  two  latter  are  very  unusual 
modes  of  entrance.  The  avenue  of  entrance  of  the  bovine  bacillus  is 
the  alimentary  tract — that  of  the  human  type,  the  respiratory  tract. 
In  a  large  majority  (60  per  cent.)  of  my  cases  the  patient  had  been  in 
association  with  a  tuberculous  individual. 

Illustrative  Cases. — Two  children,  aged  six  and  eight,  developed  pulmonary 
tuberculosis.  They  were  dispensary  patients,  and  lived  in  a  small  three-story 
tenement  house.  The  fact  that  the  two  cases  developed  at  the  same  time  seemed 
conclusive  evidence  of  a  common  source  of  infection.  Both  the  father  and  the 
mother  were  well,  and  they,  with  their  two  children,  composed  the  family.  Upon 
further  investigation  we  found  that  the  janitor  of  the  tenement  had  advanced  pul- 
monary tuberculosis,  and  that  he  was  not  at  all  careful  where  he  deposited  tuber- 
culous sputum. 

Aged  people  with  chronic  bronchitis  are  often  carriers  of  the  tuber- 
cle bacillus,  and  such  persons  are  the  most  dangerous.  They  remain 
indoors  and  infect  the  rooms.  Not  suspected  of  being  tuberculous, 
they  are  careless,  they  kiss  and  fondle,  and  often  assume  considerable 
care  of,  the  younger  members  of  the  family.  I  have  traced  several  cases 
of  tuberculous  meningitis  to  such  origin. 

Illustrative  Cases. — In  a  recent  case  the  infection  was  traced  to  the  grandfather 
whom  the  child  visited  for  four  weeks. 

A  baby  of  nine  months,  an  only  child,  died  from  tuberculous  meningitis.  No 
source  of  the  infection  could  be  discovered  until,  six  months  later,  the  mother  de- 
veloped acute  pulmonary  tuberculosis  of  a  very  active  type.  She  undoubtedly 
was  suffering  from  latent  tuberculosis  at  the  time  of  the  child's  death.  The  father 
contracted  the  disease  apparently  from  his  wife,  and  died  in  two  years.  In  all 
these  cases  there  was  a  decidedly  virulent  infection. 

Predisposing  Causes. — Among  the  predisposing  causes,  age  is  im- 
portant. The  more  tender  the  age,  the  greater  the  susceptibility. 
Any  illness  which  decreases  the  general  resistance  or  lessens  the  resist- 
ance of  the  upper  air-passages  or  lungs,  predisposes  to  the  disease. 
Thus  we  see  many  cases  following  measles,  scarlet  fever,  influenza,  and 
bronchopneumonia.  Adenoids  and  diseased  tonsils  are  eminently  pre- 
disposing causes,  particularly  favoring  tuberculous  cervical  adenitis. 
Heredity  is  less  a  factor  than  is  generally  supposed.  Often  what  passes 
for  heredity  is  a  direct  infection  from  a  tuberculous  parent,  in  whom 
the  disease  has  remained  dormant  in  the  bronchial  glands  or  elsewhere, 
and  does  not  develop  until  a  late  period. 

The  close  housing  of  children  during  the  colder  months  is  of  no 
little  importance  as  a  means  of  diminishing  resistance  to  the  bacillus. 
The  habit  of  frequent  change  of  residence  is  also  a  source  of  infection. 
A  family  moves  into  an  apartment  or  tenement  with  little  thought  or 
knowledge  of  the  previous  occupant,  and  the  owner  makes  no  effort  at 


TUBERCULOSIS  693 

painting  or  cleaning  for  the  new  tenants,  carrying  out  only  such  changes 
as  are  absolutely  necessary.  I  have  known  tuberculosis  to  develop  in 
children  occupying  an  apartment  in  which  a  tuberculous  adult  had  pre- 
viously been  domiciled.  Infection  may  take  place  through  the  blood 
of  the  mother  by  way  of  the  placental  circulation.  Cases  have  been 
reported  in  our  country  by  Jacobi  and  Wollstein,  in  which  a  tuberculous 
fetus  has  been  born  to  a  tuberculous  mother. 

Prophylaxis. — The  best  insurance  against  tuberculosis  is  a  vigor- 
ous bodily  resistance.  At  least  85  per  cent,  of  the  human  race  are 
infected  some  time  before  the  thirtieth  year,  but,  fortunately,  the 
great  majority  of  those  infected  are  able  to  withstand  the  invasion. 
Observation  with  the  von  Pirquet  test  in  different  countries,  covering 
a  large  number  of  children  of  varying  ages,  show  that  from  40  per  cent, 
to  70  per  cent,  react  positively.  The  results  demonstrate  that  a  vast 
majority  of  the  human  race  are  infected  before  the  fifteenth  year. 
Adenoids  and  diseased  tonsils  should  be  removed  from  every  child  who 
possesses  them.  Children  should  be  allowed  to  make  complete  re- 
coveries from  bronchitis,  bronchopneumonia,  influenza,  whooping- 
cough,  measles,  etc.  A  week  or  longer  from  school  is  a  matter  of  no 
moment  in  the  child's  future  from  the  standpoint  of  knowledge. 
Kissing  of  children  on  the  mouth  should  be  forbidden.  This  act  is  a 
grossly  unfair  advantage  to  take  of  an  innocent  child.  Overwork  at 
school,  in  mines,  and  in  factories  predisposes,  by  fostering  close  asso- 
ciations and  diminishing  resistance. 

The  reporting  of  tuberculous  cases,  and  the  rigid  enforcement  of 
hygienic  measures  relating  to  the  disposal  of  tuberculous  sputum, 
would  materially  lessen  the  number  of  cases. 

Infants  and  young  children  up  to  the  fourth  year  are  very  suscepti- 
ble to  tuberculosis.  During  this  period  the  child  should  have  absolutely 
no  association  with  an  open  case  in  an  adult  or  older  child.  If 
there  is  such  an  association  the  infant  will  in  all  probability  develop 
tuberculosis. 

Milk  Infection. — The  infection  of  the  bovine  type  is  preventable 
by  pasteurizing  all  milk  and  butter  which  is  not  taken  from  tested 
cows  proved  free  from  tuberculosis.  The  nutritive  qualities  of  milk 
are  not  harmed  by  heating,  but  all  children  fed  on  pasteurized  milk 
should  be  given  orange-juice. 

Municipal  Pasteurization. — Rosenel,  Calmette,  Von  Behring  and 
others  believe  that  infants  are  infected  through  the  intestinal  tract, 
the  bacilli  passing  through  the  mucous  membrane  of  that  structure 
without  injury  and  lodge  in  the  bronchial  glands  or  elsewhere  in  the 
body — remain  dormant  and  go  through  a  process  of  transmutation 
from  the  bovine  to  the  human  type,  producing  pulmonary  tuberculosis 
(human)  in  later  life. 

Relative  Frequency  in  Different  Sites. — Although  the  tonsil  is 
looked  upon  as  a  portal  for  the  frequent  entrance  of  the  disease,  tliis 
organ  itself  has  been  found  to  be  tuberculous  in  very  few  instances. 

In  90  per  cent,  of  all  cases  of  tuberculous  lymphadenitis  the  cervical 


694  THE    PRACTICE    OF    PEDIATRICS 

glands  are  involved,  and  chronic  inflammation  in  these  glands,  when 
well  advanced,  is  usually  aggravated  by  the  presence  of  infecting  or- 
ganisms of  the  staphylococcus  or  streptococcus  groups. 

Still  has  reported  important  findings  in  216  postmortem  examina- 
tions following  fatalities  from  tuberculosis  in  children.  In  63.8  per 
cent,  he  traces  the  incidence  of  the  disease  to  the  lung;  in  29.1  per  cent, 
to  the  intestine;  and  in  15  of  the  216  cases,  to  the  ear.  By  other  au- 
thorities the  frequency  of  primary  respiratory  infection  is  estimated  at 
65  to  70  per  cent.,  and  that  of  an  initial  intestinal  infection  at  15  to  30 
per  cent. 

Both  Still  and  Carr  report  finding .  caseation  of  the  mediastinal 
glands  in  81  per  cent,  of  autopsies  on  tuberculous  subjects,  while  in  a 
proportion  ranging  approximately  from  55  to  60  per  cent,  the  same 
observers  found  a  similar  condition  in  the  mesenteric  glands.  The 
mediastinal  glands  on  the  right  side  are  more  frequently  diseased  than 
those  on  the  left. 

Nearly  60  per  cent,  of  tuberculous  cases  have  shown  invasion  of  the 
mesenteric  glands;  and  in  12  of  100  autopsies  upon  children  under  two 
years  of  age,  Still  found  tuberculous  peritonitis. 

Abdominal  Tuberculosis  (Tuberculosis  of  the  Mesenteric  Gland; 
Tabes  Mesenterica) 

Tuberculosis  of  the  mesenteric  glands  is  not  uncommon  in  the  find- 
ings at  autopsy  upon  young  tuberculous  subjects.  Rarely  is  the  condi- 
tion sufficiently  developed,  in  this  country,  to  be  recognized  clinically 
independent  of  peritonitis.  My  first  postmortem  examination  upon  a 
child,  however,  was  in  a  case  of  this  character.  The  patient  was  three 
months  old,  colored.  I  have  examined  at  autopsy  two  other  cases  in 
which  there  was  uncomplicated  tabes  mesenterica  with  no  peritonitis. 
I  have  diagnosed  the  condition  in  three  other  cases  as  true  tabes 
mesenterica. 

Symptoms. — The  symptoms  include  slow  progressive  emaciation, 
slight  inconstant  elevation  of  the  temperature,  distended  abdomen, 
persistent  intestinal  indigestion,  diarrhea,  flatulence,  and  abdominal 
pain.  The  pain  is  colicky  in  character,  and  may  be  very  severe  and 
continue  over  a  considerable  period. 

Diagnosis. — A  positive  diagnosis  is  to  be  made  upon  one's  ability 
to  palpate  the  enlarged  glands.  For  critical  abdominal  examination 
I  very  often  employ  light  anesthesia.  This  renders  the  examination 
far  more  satisfactory.  The  glands  in  my  cases  were  best  felt  in  the 
right  or  left  iliac  fossa. 

The  symptoms  somewhat  resemble  those  of  chronic  appendicitis, 
and  a  rectal  examination  may  be  necessary  to  determine  if  there  is  an 
enlargement  of  the  appendix  or  adhesions  or  infiltration  about  it. 

Prognosis. — The  prognosis  is  unfavorable  in  cases  that  have  devel- 
oped sufficient  signs  for  a  diagnosis.  Still,  who  has  had  a  large  experi- 
ence in  abdominal  tuberculosis,  states  that  we  are  never  sure  of  the 


CHRONIC   TUBERCULOUS    PERITONITIS  695 

recovery  cases.  The  diseased  glands  may  at  any  time  be  the  starting- 
point  of  a  general  or  localized  inflammation,  with  the  output  of  exten- 
sive adhesions  resulting  in  a  general  tuberculous  peritonitis  or  produc- 
ing local  effects  interfering  seriously  with  the  functions  of  the  intestine. 

Illustrative  Case. — About  four  years  ago  I  performed  an  autopsy  for  a  colleague 
on  a  two-year-old  child  who  had  died  suddenly  with  symptoms  of  acute  intestinal 
obstruction.  The  child  had  had  abdominal  trouble  during  the  second  year,  and  had 
been  seen  by  different  physicians,  one  of  whom  made  a  diagnosis  of  tabes  mesen- 
terica.  The  patient  improved  and  three  months  previous  to  the  fatal  termination 
was  well,  with  the  exception  of  obstinate  constipation.  The  postmortem  showed  a 
most  remarkable  picture  of  enlarged  glands  matted  together  by  fibrinous  exudate, 
which  had  been  poured  into  the  abdominal  cavity  and  had  undergone  connective- 
tissue  formation.  The  descending  colon  resembled  a  hollow  tube  held  in  position 
by  the  surrounding  exudate.  How  the  child  had  lived  and  had  bowel  evacuations 
is  difficult  of  explanation.  The  obstruction  was  caused  by  an  angle  forming  at  the 
point  where  the  free  intestine,  filled  with  gas,  joined  the  fixed  portion. 

Treatment. — All  measures  that  will  increase  the  patient's  resistance 
should  be  employed.  An  out-of-door  life  and  the  general  management 
advised  in  treating  tuberculosis  (p.  364)  should  be  followed. 

Still  believes  that  operative  measures  are  of  value.  He  finds  that 
removal  of  the  enlarged  glands  is  to  be  advised,  as  thereby  eliminating 
a  definite  focus  of  infection.  At  the  same  time  fibrinous  bands  causing 
pain  and  symptoms  may  be  broken  up. 


CHRONIC  TUBERCULOUS  PERITONITIS 

Acute  tuberculous  invasion  of  the  peritoneum  may  be  found  in  a  few 
cases  of  general  tuberculosis.  It  is  of  no  clinical  significance,  and  has 
been  briefly  referred  to  on  p.  364. 

Chronic  tuberculous  peritonitis  is  a  comparatively  infrequent  dis- 
ease in  this  country.  In  England  and  on  the  Continent  many  more 
cases  are  seen.  Still,  of  London,  reports  266  fatal  cases  of  tuberculosis 
in  children  under  twelve  years  of  age,  45  of  whom  died  with  tuberculous 
peritonitis — a  percentage  of  16.8.  Under  two  years  of  age,  this  author 
found  12  cases  of  tuberculous  peritonitis  in  100  tuberculous  infants. 

Etiology. — A  considerable  proportion  of  the  cases  are  probably  due 
to  an  extension  from  infected  mesenteric  glands.  Through  the  lymph 
and  blood-channels  the  bacilli  may  be  carried  to  the  peritoneum  from 
any  focus. 

Pathology. — The  course  of  the  inflammation  may  be  acute  or 
chronic,  and  the  changes  produced  have  given  rise  to  a  classification  of 
several  types  of  the  disease. 

1,  The  simplest  lesions  consist  of  scattered  grayish  miliary  tubercles 
unassociated  with  the  presence  of  exudate  or  other  evidences  of  an 
advanced  process.  This  picture  is  seen  in  connection  with  a  general 
miliary  tuberculosis  which  may  have  presented  no  local  clinical  signs. 

2.  In  a  second  form  of  the  disease,  coexisting  with  miliary  tubercles 
which  are  scattered  over  the  peritoneum  in  great  number,  there  is  a 
marked  ascites  depending  on  the  predominance  of  the  element  of  exu- 
dation.    The  exudate  is  serous  and  contains  only  a  moderate  amount  of 


696  THE    PRACTICE    OF    PEDIATRICS 

fibrin.     When  the  fluid  accumulation  is  large,  the  intestines  are  floated 
up  and  the  abdominal  cavity  is  characteristically  distended. 

3.  A  third  variety  of  tuberculous  peritonitis  is  predominantly  ad- 
hesive and  unaccompanied  by  the  exudation  of  much  fluid.  The  loops 
of  intestines  become  closely  matted  together  and  the  omentum  is  rolled 
up  in  a  firm  elongated  mass.  The  typical  tubercles  are  present,  but 
have,  at  many  sites,  become  confluent  and  been  transformed  into  larger 
foci,  or  given  way  to  the  development  of  reparative  fibrous  tissue.  The 
amount  of  fluid  exudate  is  small  and  may  be  clear  or  clouded  by  the 
admixture  of  fibrin  and  flakes  of  pus. 

4.  Finally,  the  lesions  may  be  of  a  destructive  character,  consisting 
of  actual  ulcerations  caused  by  the  disintegration  of  large  caseous  foci. 
In  such  an  event,  adhesions  between  intestines,  mesentery  and  omen- 
tum are  produced  which  serve  to  confine  collections  of  pus.  These 
may  eventually  break  forth  and  discharge  externally.  Fecal  fistula© 
or  abscesses  between  adjacent  portions  of  intestine  are  not  uncommon. 

Types  of  Bacilli. — Park  and  Krumwiede  found  the  bovine  form  in 
20  of  53  cases  of  tuberculosis  between  the  fifth  and  sixteenth  years. 
In  35  children  under  five  years  the  bovine  bacillus  was  present  in  20 
cases. 

Types  of  Lesions. — The  disease  is  usually  divided  pathologically 
into  two  leading  forms — the  ascitic  and  the  plastic  or  fibrous. 

There  are  few  cases  of  the  fibrous  type,  however,  without  fiuid  in 
the  abdomen,  and  few  ascitic  cases  in  which  there  is  not  some  fibrous 
formation.  Still  found  the  proportion  of  the  fibrous  to  the  ascitic  type 
10  to  1. 

Age  of  Patients. — The  great  majority  of  cases  occur  between  the 
first  and  third  years.  Cases  developing  before  the  end  of  the  first  year 
are  rare. 

Symptoms. — Suggestive  symptoms  in  all  cases  are  abdominal  dis- 
comfort, pain,  and  distention  from  gas  or  fluid,  digestive  disturbances, 
emaciation,  and  persistence  of  all  symptoms  in  spite  of  medication  and 
careful  dieting. 

The  Ascitic  Type. — In  the  ascitic  form,  when  the  patient  first  comes 
under  observation,  the  abdomen  usually  contains  considerable  fluid. 
This  increases  rapidly  and  the  abdominal  wall  becomes  distended  and 
tense. 

There  may  be  a  temperature  of  100°  to  102°F.  An  elevation  of  the 
temperature  is,  however,  not  invariably  present:  it  is  as  often  absent. 
There  is  a  secondary  anemia,  and  the  child  becomes  emaciated  and  tires 
readily.  A  differentiation,  however,  between  tuberculous  ascities  and 
that  due  to  other  causes  may  not  be  possible  without  corroborative 
evidence  of  tuberculosis  elsewhere.  Examination  of  the  ascitic  fluid 
even  in  positive  cases  does  not  always  show  the  presence  of  the  tubercle 
bacilli.  Through  absorption  of  the  fluid,  cases  that  belong  to  the 
ascitic  type  at  flrst,  change  to  the  fibrous.  This  in  my  experience  is 
not  at  all  unusual. 

The  Plastic  Type. — In  these  cases  the  onset  is  gradual,  the  tempera- 


CHRONIC    TUBERCULOUS    PERITONITIS  697 

ture  usually  is  not  high — 100°  to  101  °F.  There  are  loss  of  appetite  and 
emaciation.  Intestinal  indigestion,  evidenced  by  tympanites  and 
occasional  diarrhea,  is  common.  There  may  be  constipation  alter- 
nating with  diarrhea,  and  there  is  almost  always  pain.  It  is  the  pain 
that  usually  attracts  the  attention  of  the  parents  to  the  child's  condi- 
tion. The  course  of  this  form  of  the  disease  is  slow  and  its  progress 
may  be  interrupted  by  periods  of  improvement. 

Diagnosis. — -It  is  rare  in  cases  of  the  fibrous  type  or  in  those  due  to 
mesenteric  lymphadenitis  not  to  find  nodules  in  either  of  the  iliac  fossae 
or  the  evidence  of  fibrous  bands  in  the  abdomen.  The  retracted,  thick- 
ened omentum,  forming  a  distinct  ridge  across  the  abdomen,  is  present 
in  many  cases.  This  may  be  confused  with  the  lower  edge  of  the  liver. 
Careful  palpation,  however,  will  demonstrate  the  band  as  thick  and 
roughened,  and  extending  well  across  the  abdomen  in  a  downward  di- 
rection toward  the  left  side.  A  space  between  the  band  and  the  lower 
edge  of  the  liver  can  usually  be  made  out. 

With  the  palpable  mesenteric  nodes  or  the  fibrous  bands,  there  will 
be  fluid  in  some  amount.  An  unfolding  of  the  umbilicus,  with  redness 
about  it,  producing  a  condition  known  as  "pointing,"  is  a  suggestive 
symptom.  Perforation  at  this  point  is' not  an  uncommon  occurrence 
in  the  experience  of  those  who  see  many  cases  of  this  disease. 

Prognosis. — About  one-half  of  the  patients  recover.  I  have  seen 
pronounced  cases  make  complete  recoveries.  It  is  a  difficult  matter, 
as  in  the  instance  cited,  to  decide  when  a  patient  is  well.  The  cases 
with  ascites  promise  better  than  do  those  of  the  fibrous  type;  and 
yet  many  of  the  latter  form  which  promise  little  make  complete 
recoveries. 

Illustrative  Case. — A  boy  three  years  old  developed  a  tuberculous  peritonitis  of 
a  pronounced  fibrous  type.  The  omental  band  could  be  seen  elevating  the  skin 
across  the  abdomen  in  a  distinct  ridge.  After  several  months  of  treatment  im- 
provement began,  and  there  was  steady  progress  toward  a  betterment  until  the 
bodies  of  the  two  upper  lumbar  vertebrae  became  involved.  The  child  made  a 
complete  recovery  eventually  from  both  conditions. 

Treatment. — The  hygienic  and  medical  management  is  similar  to 
the  treament  outlined  for  other  cases  of  tuberculosis  (p.  364).  Ade- 
quate rest,  high  proteid  diet,  open  air,  and  change  of  climate,  when  this 
may  be  supplied,  should  be  provided.  Drugs  are  of  value  only  as  a 
means  of  improving  nutritional  conditions.  A  combination  which 
seems  to  possess  real  value  in  these  cases  is  the  following : 

For  a  child  three  years  of  age : 

I^    Liq.  potassii  arsenitis njjxlviij 

Liq.  ferri  albuminati ovj 

Syr.  hypophosphitum  (calcis  et  soda) q.  s.  ad  5vj 

M.  Sig. — One  teaspoonful  in  water  after  meals. 

The  medication  is  given  for  ten  days,  then  omitted  for  five  days,  and 
then  resumed.  Interrupted  medication  may  be  continued  in  this  way 
indefinitely. 

Moderate  exercise  may  be  allowed  if  the  temperature  is  normal. 


698  THE    PRACTICE    OF    PEDIATRICS 

Operatioji. — There  appears  to  be  but  little  unanimity  of  opinion  as 
regards  the  advisability  of  operative  procedure  in  tuberculous  perit- 
onitis. Some  authors  are  ardent  advocates  and  give  statistics  to  prove 
their  contentions;  on  the  other  hand,  other  physicians,  with  equally  large 
experience,  disapprove  of  the  operation.  My  own  course  is  as  follows : 
If  there  is  a  marked  ascites  with  much  discomfort,  interfering  with 
respiration  and  heart  action  through  pressure  on  the  diaphragm,  opera- 
tion is  advised  at  once.  It  would  seem  that  early  operation  furnishes 
the  best "  chance  for  relief  in  the  acutely  active  cases.  Evidence  of 
interference  with  normal  peristalsis,  as  indicated  by  persistent  consti- 
pation and  visible  peristalsis,  means  that  intestinal  obstruction  is 
imminent,  and  under  such  conditions  immediate  laparotomy  is  advised. 
When  the  above  conditions  do  not  obtain,  I  have  found  it  advisable  to 
postpone  operation,  and  treat  the  patient  along  the  lines  already 
referred  to. 

Some  of  the  cases  seen  by  me  were  absolutely  hopeless  at  the  time, 
showing  marked  tuberculous  processes  elsewhere,  and  therefore  were 
not  considered  fit  subjects  for  operation. 

The  patient  should  be  weighed  once  a  week.  In  case  of  a  continu- 
ous loss  in  weight  and  strength  extending  over  five  or  six  weeks,  with  or 
without  fever,  in  spite  of  the  advantage  of  diet,  climate,  and  medica- 
tion, operation  is  to  be  advised,  regardless  of  the  stage  of  the  process, 
providing  always  that  there  is  not  active  tuberculous  process  else- 
where. When  the  weight  remains  stationary  or  nearly  so,  and  there 
is  no  evidence  of  advance  in  the  abdominal  lesions,  it  is  safe  to  wait  for 
a  considerable  time  before  undertaking  operative  measures. 

Heliotherapy  in  Surgical  Tuberculosis. — In  the  summer  of  1912  Dr. 
Rollier,  of  Lysin,  Switzerland,  published  his  results  in  the  treatment  of 
surgical  tuberculosis  at  the  tuberculosis  congress  in  Rome.  In  the 
town  of  Lysin  are  situated,  on  the  snow-covered  mountain,  the  pavilions 
where  his  method  of  heliotherapy  is  practised.  It  consists  in  exposing 
the  body  of  the  patient  to  the  sun's  rays  in  open  galleries  communicat- 
ing with  the  wards  and  facing  due  south.  The  actual  seat  of  disease  is 
uncovered  for  five  minutes  only,  to  begin  with,  as  there  must  be  no 
blistering  or  burning  of  the  skin ;  the  next  day  the  region  is  treated  for 
two  periods  of  five  minutes  each,  separated  by  an  interval  of  half  an 
hour;  and  on  the  third  day  these  exposures  are  lengthened  to  fifteen  or 
twenty  minutes.  At  each  seance  a  larger  area  of  skin  is  exposed  so 
that  at  the  end  of  two  weeks  the  entire  body,  except  the  head,  is  being 
exposed  to  the  rays  of  the  sun.  The  head  usually  requires  protection 
for  a  little  longer  time  so  as  to  prevent  congestion.  Plaster  jackets  are 
rarely  used,  while  abscesses  are  aspirated  and  exposed  in  the  usual 
manner.  In  the  jackets  windows  are  cut  so  that  portions,  at  least,  of 
the  body  are  exposed. 

According  to  Rollier,  improvement  is  evinced  almost  immediately. 
Fever  disappears,  hemoglobin  and  red  cells  approach  and  attain  their 
normal  standards,  while  increase  in  weight  is  most  noticeable.  Out 
of  369  cases  of  surgical  tuberculosis  treated  thus,  in  284  (78  per  cent.) 


DACTYLITIS 


699 


recovery  was  obtained;  in  48,  improvement;  in  21  the  condition  re- 
mained stationary,  while  16  (4 per  cent.)  succumbed.  In  visceral  tuber- 
culosis the  results  were  excellent.  In  27  cases  of  peritonitis  and  enteri- 
tis there  were  17  recoveries,  3  improvements,  and  3  deaths.  Certainly 
no  other  treatment  has  given  such  results. 

The  different  rays  (blue,  indigo,  violet)  each  play  a  part  in  the  cura- 
tive process  as  well  as  the  more  recently  discovered  infra-red  and  ultra- 
violet rays.  Some  are  analgesic,  some  have  a  tonic  action,  and  others 
penetrate  deeply  into  the  tissues.  There  is  no  attempt  to  utilize  any 
particular  ray  as  Finsen  did.  Experiment  has  shown  that  fully  25  or 
30  per  cent,  of  sun's  rays  are  absorbed  by  atmosphere  and  dust  and 
that  to  make  the  treat- 
ment efficient,  altitude 
is  of  prime  importance. 

DACTYLITIS 

Dactylitis  consists 
of  a  fusiform  swelling 
of  one  or  more  of  the 
phalanges.  (See  Fig. 
103.)  There  are  two 
forms  —  dactylitis 
syphilitica  and  dactylitis 
tuberculosa. 

Patholog3r.— The 
lesion  is  the  same  in 
both  types,  consisting 
of  rarefying  osteomye- 
litis. The  process  be- 
gins in  the  center  of  the  bone,  causing  an  enlargement  of  the  medullary 
canal.  At  the  same  time,  particularly  in  syphilitic  types,  there  is  a 
periostitis  with  deposit  of  bone  cells,  so  that  eventually  the  bone  is  of 
much  greater  circumference  than  other  similar  bony  parts. 

Suppuration  and  necrosis  occur.  A  mere  shell  of  bone  may  remain 
which,  on  undergoing  further  necrosis,  may  result  in  the  loss  of  the 
finger  or  toe.     The  disease  does  not  limit  itself  to  one  bone. 

Illustrative  Case. — In  a  recent  syphilitic  case  all  the  fingers  of  both  hands  were 
involved  and  also  the  metatarsals  of  both  great  toes.  The  index-  and  middle 
fingers  of  the  right  hand  suffered  most.  On  the  whole,  both  hands  were  alike  and 
appeared  almost  webbed,  due  to  the  swelling  of  the  proximal  phalanges,  while  the 
distal  ones  tapered  in  a  definite  penciled  fashion.  There  was  apparently  no  pain, 
and  the  infant  used  the  hands  with  perfect  freedom.  The  x-ray  plates  showed  a 
destructive  osteitis  involving  the  bones  of  both  hands. 

The  radiograph  reproduced  in  Fig.  104  shows  very  graphically  the 
bone  change  taking  place  in  tuberculous  dactylitis.  In  radiograph  A 
are  shown  the  necrosis  that  has  taken  place  in  first  phalanx  of  the 
middle  and  little  fingers.  Radiograph  B,  taken  10  weeks  later,  shows 
a  re-establishment  of  the  bone  structure.    Radiograph  C  shows  the 


Fig.  103.— Dactylitis. 


700 


THE    PRACTICE    OF    PEDIATRICS 


J3 

3 


1 


TUBERCULIN  701 

bones  entirely  restored  to  normal.  The  patient,  a  child  of  8  months, 
had  the  advantage  of  hehotherapy. 

Differentiation. — Differentiation  between  the  two  types  from  the 
dinical  appearance  is  impossible.  When  the  lesion  is  multiple,  it  is 
more  apt  to  be  of  syphilitic  origin,  although  this  is  by  no  means  certain, 
as  I  have  seen  multiple  spina  ventosa.  The  von  Pirquet  test  and  the 
Wassermann  reaction,  in  the  absence  of  disease  elsewhere,  will  be  re- 
quired to  establish  the  diagnosis,  as  the  symptoms  and  appearance  are 
identical  in  both  forms. 

Treatment. — Aside  from  the  antisyphilitic  treatment,  the  manage- 
ment of  the  two  types  is  the  same.  Absolute  rest  of  the  parts  appears 
to  be  essential  for  success.  This  is  best  secured  by  the  use  of  splints, 
which  must  be  kept  bound  on  the  fingers  for  months  in  such  a  way  as 
effectually  to  immobihze  them.  In  a  recent  case  of  the  tuberculous 
form,  successfully  treated  in  this  way,  the  finger  was  kept  in  splints  for 
six  months.  When  abscess  and  necrosis  occur,  the  case  must  be  treated 
along  surgical  lines,  the  immobility  of  the  parts  being  maintained  as 
completely  as  the  conditions  allow. 

The  Newer  Diagnostic  Methods 
tuberculosis 

Tuberculin  is  used  as  a  diagnostic  agent  to  detect  early,  latent,  or 
doubtful  cases  of  tuberculosis;  it  may  be  applied  in  three  different 
ways :  suhcutaneously,  cutaneously,  and  in  the  eye. 

Subcutaneous  Inoculation. — The  dose  used  for  diagnosis  is  larger 
than  that  allowable  for  immunization  purposes,  from  }{q  to  5  or  10 
milKgrams  being  used,  according  to  the  age  of  the  child.  If  the  patient 
is  tuberculous,  the  injection  is  followed  in  eight  to  twenty-four  hours 
by  a  rise  of  temperature,  a  certain  amount  of  malaise,  tenderness  at 
the  seat  of  injection,  and  rales  over  the  suspected  lung  area.  The  re- 
action is  general  as  well  as  local.  The  temperature  falls  within 
twenty-four  hours.  No  reaction  occurs  in  non-tuberculous  cases, 
while  in  95  per  cent,  of  those  of  tuberculosis  the  test  is  followed  by  a 
positive  reaction.  Absolute  exclusion  of  tuberculosis,  however,  be- 
cause of  a  negative  result,  is  not  possible.  The  test  is  applicable 
only  to  cases  which  do  not  run  a  temperature  over  37.7°C.  (100°F.), 
and  is  useful  in  doubtful  and  obscure  cases.  It  may  be  necessary  to 
repeat  the  inoculations  two  or  three  times  before  a  positive  reaction 
occurs;  the  initial  small  dose  of  Ho  milligram  being  followed  in  three 
days  by  another  of  one  milligram,  and  again,  if  necessary  in  three  days 
by  another  of  3  or  5  milligrams  in  older  children. 

A  second  subcutaneous  test  is  the  puncture  or  stick  reaction  of  Ham- 
burger, who  claims  that  his  is  the  most  sensitive  test.  In  older  children 
Mooo  to  Koo  milligram  of  tuberculin  is  injected  just  beneath  the  skin. 
Within  twenty-four  hours  the  local  reaction  begins  and  lasts  for  five  or 
six  days.  The  redness  and  induration  are  visible  at  the  point  entered 
by  the  needle,  and  also  at  the  place  where  the  injected  fluid  is  deposited. 


702  THE    PRACTICE    OF    PEDIATRICS 

Cutaneous  Inoculation. — This  method  of  vaccination  with  tubercu- 
lin was  introduced  by  von  Pirquet.  A  small  superficial  scarification 
is  made  on  the  forearm,  and  a  drop  of  undiluted  tuberculin  is  applied. 
An  untreated  scarified  area  of  equal  size  is  made  at  the  same  time  for 
control  purposes.  In  cases  of  active  tuberculosis  the  reaction  begins 
wdthin  twenty-four  hours.  A  small  red  papule  forms,  surrounded  by  a 
limited  area  of  redness  and  induration.  In  four  to  eight  days  the  nodule 
has  disappeared.  The  control  scarification  heals  without  any  inflam- 
matory sign.  Von  Pirquet  himself  uses  a  fine  boring  instrument  in- 
stead of  scarifying.  The  method  is  most  valuable  in  infants  and  chil- 
dren under  two  years  of  age.  A  positive  reaction  is  accepted  by  von 
Pirquet  as  proof  positive  of  tuberculosis.  A  negative  reaction,  on  the 
whole,  means  absence  of  any  tuberculous  focus.  My  own  observation 
substantiates  von  Pirquet 's  statement;  a  positive  reaction  means 
tuberculosis  in  almost  every  case.  This  we  have  proved  by  other 
means,  such  as  examination  in  spinal  fluid  and  sputum,  and  autopsy 
findings. 

In  the  last  days  of  a  miliary  tuberculosis  the  reaction  fails  to  appear 
in  -about  half  the  cases.  Furthermore,  in  cachectic  conditions  from 
any  cause  the  reaction  does  not  appear.  During  the  eruptive  stage  of 
measles  it  is  absent  in  100  per  cent,  of  tuberculous  cases,  while  in 
scarlet  fever  the  negative  result  is  less  constant,  the  reaction  failing 
to  appear  in  85  per  cent,  of  the  cases.  After  the  eruption  has  disappeared 
a  von  Pirquet  reaction  may  be  obtained.  Tuberculous  patients  suf- 
fering from  diphtheria  or  typhoid  fever  also  fail  in  some  instances  to 
react  to  the  cutaneous  tuberculin  test. 

Differential  Cutaneous  Reaction. — Detre  devised  this  method  of 
diagnosing  human  from  bovine  tuberculous  infection.  He  used  the 
filtrates  of  bouillon  cultures  of  human  and  bovine  tubercle  bacilli, 
applying  them  by  the  von  Pirquet  cutaneous  method,  making  the  scari- 
fications and  the  applied  drop  of  fluid  as  nearly  alike  as  possible.  The 
diagnosis  is  determined  by  the  relative  size  of  the  resulting  reaction 
papules,  which  Detre  carefully  measures.  Thus  far,  most  observers 
find  that  in  the  majority  of  cases  the  two  reactions  are  equally  marked, 
and  it  has  not  yet  been  established  that  the  differential  diagnosis 
between  human  and  bovine  tubercle  bacillus  infection  is  possible  by 
this  means. 

The  Moro  Inunction  Test  for  Tuberculosis. — Equal  parts  of  old 
tuberculin  and  anhydrous  lanolin  are  used  in  the  form  of  a  salve.  The 
dose  is  about  one  gram  of  the  ointment,  rubbed  into  an  area  of  healthy 
skin  about  5  cm.  in  diameter.  The  application  is  made  in  the  epigas- 
tric or  submammary  region,  a  rubber  finger-cot  or  glove  being  used  to 
rub  the  ointment  into  the  skin  for  three-fourths  of  a  minute  or  more. 
The  inoculated  area  is  exposed  to  the  air  for  ten  to  twenty  minutes, 
and  no  dressing  is  applied.  It  is  well  to  clean  the  site  of  the  inunction 
with  alcohol  before  applying  the  salve,  and  also  to  ring  the  inoculated 
area.  A  control  with  plain  lanolin  is  made  on  another  part  of  the  skin. 
The  reaction  manifests  itself  in  ten  to  seventy-two  hours,  but  in  the 


TUBERCULIN    SKIN    REACTIONS    IN    INFANCY  703 

majority  of  cases  it  does  not  appear  later  than  the  second  day.  The 
eruption  which  appears  is  papulovesicular  in  character,  with  an 
erythematous  areola  around  the  individual  papules.  In  a  severe  re- 
action the  areolae  may  coalesce.  The  papules  vaiy  in  number  from 
very  few  (1  to  4)  to  very  many  (50  to  100).  Itching  sometimes  occurs. 
The  eruption  persists  for  several  days;  in  severe  cases  it  may  be  appar- 
ent for  seven  to  ten  days,  and  may  be  followed  by  pigmentation  and 
desquamation.  The  test  is  simple  and  harmless.  As  a  rule,  the  von 
Pirquet  reaction  is  fully  developed  several  hours  before  the  inunction 
(Moro)  reaction. 

Ophthalmo -reaction. — This  was  first  described  by  Wolff-Eisner  and 
shortly  afterward  by  Calmette,  and  consists  of  the  instillation  of  one 
drop  of  0.5  per  cent,  solution  of  tuberculin  into  the  conjunctival  sac 
of  the  healthy  eye  of  the  patient.  Within  twelve  hours  swelling  and 
redness  are  at  their  height,  and  gradually  subside  in  twelve  hours  more. 

The  von  Pirquet  cutaneous  test  answers  every  purpose. 

The  advantage  of  the  cutaneous  method  over  the  subcutaneous  is 
that  it  obviates  the  possibility  of  spreading  the  tuberculous  process, 
since  no  general  reaction  follows  its  application.  Both  local  methods 
are  based  upon  the  principle  that  in  the  course  of  a  tuberculous  infec- 
tion all  the  cells  of  the  body  are  sensitized  to  the  products  of  the 
tubercle  bacillus.  When,  therefore,  a  minute  quantity  of  such  products 
(tuberculin)  is  brought  into  direct  contact  with  a  sensitized  and  vas- 
cular tissue  like  the  skin  or  conjunctiva,  a  rapid  inflammatory  re- 
sponse occurs. 

TUBERCULIN  SKIN  REACTIONS  IN    INFANCY 

Dr.  Alan  Brown,  *  in  a  study  of  650  hospital  cases,  found  that  70 
per  cent,  of  the  cases  under  two  years  of  age  giving  a  positive  reac- 
tion proved  fatal.  The  lesions  were,  with  but  rare  exceptions,  general 
in  distribution. 

That  infants  show  a  high  degree  of  susceptibility  to  tuberculosis 
was  shown  by  the  fact  that  of  61  infants  in  whom  a  definite  history  of 
exposure  could  be  obtained,  41  responded  to  the  test,  and  of  these,  37 
died  of  tuberculosis. 

In  infancy  a  negative  cutaneous  reaction,  except  in  moribund  cases 
or  in  children  suffering  from  any  very  acute  infection,  is  almost  conclusive 
evidence  against  the  existence  of  a  tuberculous  focus. 

Among  100  consecutive  cases  of  tuberculosis,  95  gave  a  positive  re- 
action, the  remaining  5  patients  being  moribund  on  admission  to  the 
hospital. 

In  a  child  in  whom  tuberculosis  is  suspected  the  test  should  be  re- 
peated if  at  first  it  proves  negative. 

*  "Archives  of  Pediatrics,"  July,  1913. 


704 


THE    PRACTICE    OF    PEDIATRICS 


CHART  SHOWING  THE  HIGH  DEGREE  OF  MORTALITY  IN  INFANTS 
RESPONDING  TO  THE  CUTANEOUS  TEST.  ALL  FATAL  CASES 
PROVED  TUBERCULOUS  EITHER  BY  AUTOPSY  OR  THE  FINDING 
OF  BACILLI  IN  SPUTUM  OR  CEREBROSPINAL  FLUID 


Age 

Num- 
ber OF 
Cases 

Num- 
ber 
with 
Posi- 
tive 
Reac- 
tion 

Number  of 
Positive 
Cases  with 
Autopsy  or 
Bacterio- 
LOGic  Exam- 
ination 

Number  of  Posi- 
tive Cases 
Proved  to  Be 
Tuberculous  by 
Autopsy  or  Bac- 
TERioLOGic  Find- 
ings 

Number 
OF  Nega- 
tive Cases 

THAT 

Came  to 
Autopsy 

Number  of 
Negative  Cases 
Which  Showed 
NO      Tubercu- 
losis at 
Autopsy 

1  to  3 

.    62 

3 

3 

3 

10 

10 

months 

or  100  per  cent, 
of     +     reac- 
tions. 

3  to  6 

102 

7 

6 

6 

13 

13 

months 

or    85  per  cent. 

6  to  12 

218 

43 

35 

35 

19 

18 

months 

or    81  per  cent. 

Test    not    re- 
ported     in 
one  case. 

12  to  18 

156 

37 

20 

20 

15 

15 

months 

or    54  per  cent. 

18  months  to  2 

112 

24 

15 

15 

4 

4 

years 

114 

or    62  per  cent. 

Total,  0  to  2 

650 

79 

79 

61 

60 

years 

or    70  per  cent, 
of     +     reac- 
tions. 

CHART  SHOWING  THE  BEARING  OF  EXPOSURE  TO  TUBERCULOSIS 
ON  THE  MORTALITY  IN  THE  INFANT 


Age 

Number  or 
Cases 

Number  of 

Cases  with  a 

Definite 

Family  History 

Number  of  Cases 
with  Definite 
Family  History 
that  Reacted 

Mortality  op 
Cases  with  Defi- 
nite Family 
History  that 
Reacted 

1  to     3  months 

3  to     6  months 

6  to  12  months 

12  to  18  months 

18  months    to     2 

years 

62 
102 
218 
156 
112 

4 

8 

30 

10 

9 

3 

4 

20 

10 

4 

3 

4 

20 

6 

4 

Total,  0  to  2  years 

650 

61 

41 

37 

or  60  per  cent. 

of  those  giving 

a     history     of 

contact. 

WASSERMANN  TEST  FOR  SYPHILIS 

The  Wassermann  serum  reaction  is  the  apphcation  of  the  comple- 
ment fixation  or  deviation  test  to  the  diagnosis  of  syphiUs.  As  intro- 
duced by  Wassermann,  Neisser,  and  Bruck,  it  required  the  use  of 
guinea-pig  complement,  the  serum  to  be  tested,  antigen  consisting 
of  extract  of  syphilitic  liver,  and  a  sheep's  hemolytic  system.     By 


NOGUCHI   BUTYRIC-ACID    TEST  705 

sheep  hemolytic  system  is  meant  an  immune  rabbit  serum  prepared 
by  inoculating  rabbits  with  washed  sheep's  erythrocytes,  and  a  sus- 
pension of  washed  red  blood-cells  of  the  sheep.  In  the  presence  of 
fresh  guinea-pig  serum  (complement)  such  an  immune  serum  has  the 
power  of  hemolyzing  the  red  blood-cells.  In  the  same  way  human 
hemolytic  system  means  the  combination  of  washed  human  erythrocytes 
and  an  immune  serum  prepared  by  inoculating  rabbits  with  washed 
red  blood-cells  of  the  human  type. 

If  the  serum  to  be  tested  contains  immune  bodies  specific  to  the 
antigen  used,  these  will,  in  the  presence  of  complement,  unite  with  each 
other  and  bind  the  complement.  The  addition  of  the  hemolytic  sys- 
tem will  then  cause  no  change  in  the  tubes,  ^.  e.,  hemolysis  will  not 
occur.  If  the  antigen  and  the  immune  serum  are  not  specific,  then  the 
complement  is  left  free  to  unite  with  the  hemolytic  system  and  hemoly- 
sis occurs.     This  is  called  the  complement  fixation  or  deviation  test. 

As  simplified  by  Noguchi,  the  test  requires  much  smaller  quantities 
of  guinea-pig  complement,  the  serum  to  be  tested,  antigen  consisting 
of  human  or  animal  tissue  extract,  and  human  hemolytic  system.  For 
practical  purposes  one  cubic  centimeter  of  the  patient's  blood  will  give 
an  ample  amount  of  serum  for  the  test. 

The  Wassermann  seroreaction  is  positive  in  98  per  cent,  of  cases  of 
congenital  syphilis,  but  only  in  66  per  cent,  of  latent  syphilis.  During 
the  primary  stage  of  acquired  syphilis  90  per  cent,  of  the  cases  give  a 
positive  Wassermann  test,  during  the  secondary  stage,  96  per  cent.; 
and  during  the  tertiary  stage,  83  per  cent,  react  positively. 

Craig  has  found  that  the  reaction  may  disappear  from  two  to  four 
weeks  after  the  institution  of  mercurial  treatment,  but  it  may  return 
when  the  treatment  is  stopped ;  therefore  it  is  not  established  that  the 
disappearance  of  the  reaction  justifies  the  conclusion  that  the  disease 
has  been  cured,  and  that  treatment  may  be  discontinued. 

Noguchi  found  that  after  treatment  with  salvarsan  the  reaction 
may  disappear  within  two  weeks  in  promptly  cured  cases,  although  it 
may  not  do  so  for  four  or  five  weeks. 

NOGUCHI  BUTYRIC-ACID  TEST  FOR  SYPHILIS 

This  test  is  based  upon  the  fact  that  the  globulin  reaction  in  the 
blood-serum  and  in  the  cerebrospinal  fluid  is  increased  in  syphilis.  In 
the  case  of  the  blood-serum  the  test  is  too  complicated  to  be  used  any- 
where except  in  a  highly  equipped  laboratory,  and,  moreover,  it  is  not 
needed  in  children,  since  Wassermann 's  serum  reaction  answers  all 
practical  purposes.  Applied  to  the  cerebrospinal  fluid,  the  Noguchi 
test  is  very  simple  and  is  carried  out  as  follows:  One  or  two-tenths  of 
a  c.c.  of  cerebrospinal  fluid,  which  must  be  absolutely  free  from  blood, 
is  mixed  with  ^^  c.c.  of  a  10  per  cent,  solution  of  butyric  acid  in  normal 
saline  and  boiled.  Then  3^10  c.c.  of  normal  sodium  hydroxid  solution 
is  quickly  added,  and  the  whole  is  boiled  for  a  few  seconds.  A  granu- 
lar or  floccular  precipitate  indicates  a  positive  reaction.  The  appear- 
45 


706  THE    PRACTICE    OF    PEDIATRICS 

ance  of  the  precipitate  within  a  few  minutes  indicates  a  considerable 
increase  in  globuHn,  while  weaker  reactions  may  not  appear  for  an  hour. 
Two  hours  should  be  the  time  limit. 

Normal  cerebrospinal  fluid  with  this  test  gives  a  slight  opalescence 
and  occasionally  turbidity,  but  the  granular  precipitate  does  not  occur 
at  all  or  only  after  the  time  limit  has  been  reached. 

A  positive  reaction  occurs  with  the  cerebrospinal  fluid  from  any  case 
of  syphilitic  or  parasyphilitic  affection,  and  also  in  all  acute  inflamma- 
tions of  the  meninges,  whether  due  to  the  meningococcus,  the  tubercle 
bacillus,  the  pneumococcus,  the  streptococcus,  or  the  influenza  bacillus. 
The  reaction  is  also  positive  in  the  early  stage  of  poliomyelitis.  Such 
conditions  can,  of  course,  be  readily  differentiated  from  syphilis.  In 
acute  luetic  meningitis  the  presence  of  Treponema  pallidum  in  the  cere- 
brospinal fluid  will  serve  to  exclude  the  other  forms  of  meningitis. 
Such  a  case  has  been  reported  by  Rach*  in  a  child  four  months  old.  In 
hydrocephalus,  the  cerebrospinal  fluid  gives  a  positive  butyric  acid 
test  in  cases  which  are  of  syphilitic  origin.  When  the  amount  of  cere- 
brospinal fluid  is  increased  without  inflammation  of  the  meninges,  as 
sometimes  happens  in  pneumonia,  the  fluid  does  not  give  a  positive 
butyric  acid  test. 

In  children  Noguchi's  test  is  most  valuable  in  differentiating  be- 
tween inflammatory  and  non-inflammatory  conditions  of  the  meninges. 

LUETIN  TEST 

The  luetin  test  was  originated  by  Noguchi,  and  is  based  upon  the 
fact  that  individuals  who  have  been  affected  for  some  time  with  certain 
pathogenic  organisms  develop  a  hypersensitiveness  to  those  organisms 
or  their  constituents.  Emulsions  of  pure  cultures  of  Treponema  paUi- 
dum  killed  by  heat  are  prepared,  and  0.057  c.c.  injected  into  the  skin 
of  the  upper  arm  by  means  of  a  very  fine  needle.  A  control  is  made  on 
the  other  arm.  In  positive  reactions  a  red,  indurated  papule  forms 
within  twenty-four  to  forty-eight  hours,  and  is  surrounded  by  a  dif- 
fuse zone  of  redness.  Induration  and  redness  increase  for  three  or 
four  days,  then  subside,  and  the  thickening  disappears  within  a  week. 
In  cases  of  late  hereditary  syphilis,  the  papule,  instead  of  subsiding, 
may  go  on  to  the  formation  of  a  pustule,  which  heals  within  a  week, 
leaving  almost  no  scar.  Very  rarely  the  reaction  may  be  delayed,  so 
that  after  three  days  the  result  is  called  negative,  yet  after  ten  days  or 
longer  small  pustules  form  and  heal  in  the  usual  way.  Marked  con- 
stitutional symptoms  very  rarely  accompany  the  reaction.  A  slight 
rise  of  temperature  lasting  for  a  day  is  the  rule  in  positive  cases. 

In  non-syphilitic  patients  there  appears,  twenty-four  hours  after 
the  application  of  the  emulsion,  a  small  area  of  erythema  without  pain, 
itching,  or  induration.  Occasionally  a  small  papule  forms  within 
twenty-four  to  seventy  hours;  it  also  disappears  without  induration. 

The  reaction  is  apparently  specific  for  syphilis,  and  persists  as  long 
*"Jahrb.  f.  Kinderh.,"  1912. 


THE    WIDAL   REACTION  707 

as  Treponema  pallidum  survives  in  the  body.  It  is  specially  useful  in 
late  cases  in  which  the  spirochete  can  no  longer  be  demonstrated  micro- 
scopically and  in  which  the  Wassermann  reaction  is  indecisive.  It 
seems  to  outlast  the  seroreaction  after  antisyphilitic  treatment  has  been 
given.  In  cases  of  hereditary  syphilis  it  is  present  in  91  per  cent,  to 
100  per  cent,  of  the  cases. 

THE  WIDAL  REACTION  FOR  TYPHOID  FEVER 

To  make  Widal  tests  it  is  necessary  to  keep  in  stock  a  well-agglu- 
tinating strain  of  typhoid  bacillus.  A  bouillon  or  agar  culture  which 
has  grown  not  longer  than  eighteen  to  twenty  hours  should  be  used  for 
the  reaction.  The  blood  to  be  tested  should  be  obtained  in  a  small  glass 
tube  of  the  Wright  pattern,  0.5  to  1  c.c.  in  amount,  sealed  at  both  ends, 
and  the  serum  allowed  to  separate.  Sterile  physiologic  salt  solution 
is  used  as  the  diluent.  A  porcelain  palette  with  six  or  more  cup- 
like depressions  is  a  convenient  receptacle  for  holding  the  dilutions,  if 
the  microscopic  method  is  used. 

By  means  of  a  capillary  tube  marked  by  a  wax  pencil  1  drop  of 
serum  and  9  drops  of  salt  solution  are  mixed  in  one  of  the  palette  cups, 
making  a  dilution  of  1  :  10.  From  this  stock  other  dilutions  are  made ; 
1  drop  to  4  of  salt  solution  equals  a  dilution  of  1 :  50,  etc.  The  addi- 
tion of  1  drop  of  culture  to  1  drop  of  a  1 :  10  dilution  of  serum  makes  a 
dilution  of  1:20.  This  is  examined  on  a  hollow  slide  with  a  No.  7 
lens.  Controls  of  the  culture  alone,  and  of  culture  plus  normal  serum, 
should  be  made  at  the  same  time.  Cessation  of  motion  and  clumping 
of  the  bacilli  within  one-half  to  one  hour,  in  a  dilution  of  1 :  40  or 
1 :60,  constitutes  definite  proof  of  typhoid  infection. 

The  microscopic  method  should  be  employed  by  preference, 
and  the  dilutions  made  in  small  test  tubes.  The  tubes  are  placed 
in  the  incubator  at  37.5°C.  for  one  hour  and  then  in  the  ice-chest 
over-night.  The  reaction  can  be  read  at  a  glance.  The  clumped 
bacilli  fall  to  the  bottom  of  the  tube  and  leave  the  serum  quite  clear, 
while  the  control  remains  turbid  and  smooth.  The  quantitj'^  of  serum 
required  is  very  small,  0.2  cm.  being  sufficient  to  make  all  necessary 
dilutions.  Each  tube  may  contain  0.8  cm.  of  diluted  serum  and  0.2  cm. 
of  bacillary  suspension,  making  a  total  of  1.0  cm.  Agglutination 
in  a  dilution  of  1-40  or  1-60  may  be  looked  upon  as  a  positive  reaction. 

With  blood  dried  on  a  slide  the  test  cannot  be  accurately  made. 
Cultures  of  typhoid  bacilli  killed  with  formalin  have  been  used  for  mak- 
ing the  Widal  test,  but  the  method  has  nothing  to  recommend  it. 

The  Widal  reaction  does  not  give  positive  results  before  the  end  of 
the  first  week  or  the  beginning  of  the  second  week  of  typhoid.  It  may 
continue  to  be  positive  throughout  convalescence  and  for  a  period  of 
six  to  eight  weeks.  Occasionally  its  appearance  is  deferred  until  con- 
valescence or  until  a  relapse  comes  on,  but  it  is  present  at  some 
time  during  an  attack  of  typhoid  fever  in  over  95  per  cent,  of  all 
cases. 


708  THE    PRACTICE    OF   PEDIATRICS 


ANAPHYLAXIS 


The  second  introduction  of  a  foreign  soluble  proteid  at  an  appro- 
priate interval  after  the  first  introduction  of  that  same  proteid  causes  a 
train  of  symptoms  designated  by  the  term  anaphylaxis.  The  first  dose 
sensitizes  the  organism,  while  the  second  dose  intoxicates.  The  time 
required  for  sensitization  is  ten  days  or  longer,  and  its  duration  has 
been  found  to  be  as  long  as  seven  years. 

The  therapeutic  use  of  immune  sera,  the  majority  of  which  are  de- 
rived from  horses,  gave  rise  to  anaphylactic  phenomena  which  von 
Pirquet  and  Schick  recognized  and  called  serum  disease.  Some  pa- 
tients react  after  a  first  dose  of  serum,  the  symptoms  appearing  eight 
or  ten  days  after  its  injection,  and  consisting  of  fever,  skin  eruptions, 
muscle  and  joint  pains,  and  glandular  swellings.  Such  patients,  after 
the  administration  of  a  second  dose,  develop  symptoms  after  a  few  hours 
or  only  after  several  days.  The  immediate  reaction  is  characterized 
by  a  local  edema  at  the  site  of  the  injection,  increasing  slowly  for 
twenty-four  hours,  and  then  disappearing  in  two  to  five  days.  Fever 
and  skin  eruptions  are  also  present,  and  in  a  small  percentage  of  cases 
nausea,  vomiting,  and  even  collapse  may  occur.  When  the  symptoms 
are  delayed  for  several  days,  they  usually  occur  suddenly  and  disappear 
within  a  day.  They  are  similar  to  those  following  the  injection  of  the 
first  dose  of  serum. 

In  individuals  who  are  asthmatic  or  afflicted  with  an  idiosyncrasy 
to  the  odor  of  horses,  a  first  dose  of  horse  serum  may  cause  an  attack 
of  respiratory  distress  with  cyanosis  or  else  of  cardiac  weakness  with  a 
fatal  ending.  In  such  cases  we  must  assume  that  the  sensitization  was 
either  inherited  or  acquired  through  the  lungs  or  through  the  stomach. 
Experimental  data  support  all  three  assumptions. 

The  tubercuHn  reaction  is  a  local  anaphylaxis  in  individuals  sensi- 
tized to  the  proteids  of  the  tubercle  bacillus. 

Hay-fever  is  a  local  anaphylaxis  to  the  protein  constituent  of  cer- 
tain pollens. 

Drug  and  food  idiosyncrasies  are  anaphylactic  in  character. 


XVIL  UNCLASSIFIED  DISEASES 

RHEUMATISM 

In  a  considerable  proportion  of  the  population  there  exist  certain 
physical  characteristics  which  set  these  individuals  apart  in  a  class  by 
themselves.  The  constitutional  condition  referred  to  is  well  recognized, 
and  various  designating  terms  have  been  applied  to  it,  such  as  the 
rheumatic  diathesis,  the  rheumatic  complex  (Still),  lithemia  (Osier), 
and  lithemic  diathesis.  The  condition  is,  to  be  sure,  but  little  under- 
stood. Nevertheless,  if  we  admit  that  rheumatic  fever  (acute  articular 
rheumatism)  is  due  to  a  specific  infecting  agent,  we  must  also  admit 
that  there  is  a  favorable  field  for  activity  of  this  agent  in  certain 
members  of  the  human  race.  Children  who  have  the  rheumatic 
symptom-complex  as  described  below  are  those  who  most  frequently 
develop  acute  rheumatism— articular  (rheumatic  fever)  and  endo- 
cardial (endocarditis) . 

The  more  prominent  features  of  the  rheumatic  symptom-  complex 
comprise  lack  of  resistance  to  infection  of  the  respiratory  mucous 
membranes  and  the  tonsils;  pronounced  lack  of  nervous  balance,  mani- 
fested by  habit  spasm;  and  a  tendency  to  a  spasmodic  condition  of 
the  respiratory  tract,  as  seen  in  bronchial  spasm  and  catarrhal  laryn- 
gitis. Another  peculiarity,  as  relates  to  the  nervous  system,  is  absence 
of  control  during  play;  the  patients  become  much  excited,  and  waste 
much  energy  over  trifles.  In  my  consulting-rooms  I  have  seen  such 
children  in  ceaseless  activity,  which  they  apparently  could  not  control. 
They  are  very  apt  to  lack  concentration.  They  are  the  children  who 
have  frequent  ''growing  pains"  and  suffer  from  periodic  stomach  and 
intestinal  crises.  They  are,  furthermore,  subject  to  eczema  and  urti- 
caria. Children  of  this  type  are  the  offspring  of  those  who  have  been 
similarly  affected,  or  who  have  what  they  have  learned  to  designate 
as  rheumatism,  lithemia,  gout,  uric-acid  diathesis,  etc. 

Often  in  the  offspring  of  these  individuals  will  be  found  a  combina- 
tion of  the  above  tendencies;  the  association  of  habit  spasm,  chorea, 
and  endocarditis;  of  eczema,  articular  rheumatism,  spasmodic  bron- 
chitis, asthma,  tonsillitis,  catarrhal  laryngitis,  and  frequent  rhinitis; 
of  tonsillitis,  growing  pains,  chorea,  endocardial  and  articular  rheuma- 
tism; the  association  of  cyclic  vomiting,  tonsillitis,  and  the  nervous 
manifestations  of  bronchial  spasm  with  acute  bronchitis.  In  two  boys, 
brothers,  who  had  cyclic  vomiting,  there  was  invariably  an  attack  of 
tonsillitis  first  and  then  the  vomiting,  which  was  in  turn  followed  by 
asthmatic  bronchitis.  None  of  the  attacks  were  verj^  severe,  but  each 
time  the  same  sequence  was  carried  out.  I  have  witnessed  the  above 
associations  in  too  many  cases  to  ascribe  them  to  a  coincidence. 

709 


710  THE    PRACTICE    OF    PEDIATRICS 

Further,  it  is  this  type  of  child  who  develops  articular  rheumatism  and 
endocarditis. 

Question:  Has  this  class  of  children  rheumatism?  The  answer  is 
not  easy.  They  are  suffering  from  a  toxic  process  which  manifests 
itself  in  different  ways,  even  in  the  same  child,  and  often  in  a  way  that 
bears  no  relation  to  normal  growth  and  development.  The  condition, 
whatever  it  may  be,  constitutes  an  entity.  Examination  of  the  blood 
and  urine  tells  us  nothing  of  consequence.  It  is  this  "entity"  that 
furnishes  the  field  of  action  for  the  immediate  pathogenic  agent  of 
acute  rheumatism,  as  evidenced  by  the  joint  and  heart  involvement. 
Whether  chorea  is  to  be  placed  in  this  class  or  is  a  manifestation  of 
selective  action  of  the  systemic  toxemia  is  a  matter  to  be  decided. 
Poynton  and  Paine  claim  to  have  demonstrated  the  diplococcus  in 
the  cortex. 

Etiology. — The  chemicophysiologic  defect  appears  to  be  in  the  liver, 
in  the  nature,  probably,  of  defective  oxidation.  At  any  rate,  the  usual 
bodily  functions  are  not  apparently  involved.  If  the  patient  of  this 
type  shows  physical  defects,  it  is  more  from  the  effects  of  the  various 
ailments  occasioned  than  from  the  results  of  the  toxemia  on  the  organs. 

The  age  incidence  is  of  interest.  Infants  who  suffer  from  eczema, 
who  are  susceptible  to  bronchitis,  and  in  whom  it  is  of  the  spasmodic 
type,  often  show  the  rheumatic  tendencies  later  in  life.  The  more 
active  manifestations,  however,  do  not  appear  until  the  child  has  passed 
the  period  of  infancy. 

The  observations  and  conclusions  arrived  at  have  been  made  in 
private  practice.  The  hospital  does  not  furnish  an  opportunity  for 
observations  on  a  child,  carried  through  several  years,  as  is  necessary 
in  order  to  know  the  patient  from  every  standpoint.  Those  who  have 
not  had  a  large  private  work  with  children  for  a  considerable  period,  or 
who  have  not  carefully  watched  their  patients,  will  not  appreciate  the 
conclusions  expressed. 

Treatment. — It  is  obvious  that  children  of  the  above  type  show  a 
particular  predisposition  to  certain  affections,  and  a  decided  lack  of  re- 
sistance to  a  particular  form  of  infection — that  which  occasions  acute 
rheumatism.  The  prevention  of  cyclic  vomiting,  spasmodic  bronchitis 
(recurrent),  chorea,  and  the  other  conditions  referred  to  depends  upon 
a  proper  management  of  the  vice  of  constitution.  In  tonsillitis  two 
factors  are  operative:  the  vice  of  constitution  predisposes  to  attacks, 
producing  diseased  tonsils,  which  adds  the  feature  of  local  infection  of 
different  kinds,  and  which  necessitates  the  removal  of  the  tonsils.  ' 
Growing  pains,  habit  spasm,  tendency  to  recurrence  of  eczema,  and  | 
the  various  nervous  manifestations  enumerated  may  be  controlled 
largely  through  right  treatment  of  the  "rheumatic  complex." 

The  first  and  most  important  step  in  the  treatment  relates  to  diet. 

Diet. — These  children  have  a  poor  fat  and  sugar  capacity,  particu- 
larly for  cane-sugar  and  cow's-milk  fat.  The  nearer  the  approach  to 
a  vegetable  and  cereal  diet,  the  better  for  the  patient. 

The  nitrogenous  foods  allowed  are  poultry,  fish,  and  egg-whites. 


RHEUMATISM  711 

Sugar  of  the  arts  is  not  to  be  permitted.  Vegetables  and  stewed  fruits 
and  skimmed  milk  puddings  may  be  freely  used.  Skimmed  milk  or 
buttermilk  may  be  given  with  the  morning  and  evening  meal.  All 
cereals  are  permissible. 

It  will  be  seen  that  there  is  no  trouble  in  estabHshing  a  well- 
balanced  ration.  Children  will  readily  learn  to  do  without  sugar. 
There  is  little  or  no  trouble  in  feeding  cereals  without  sugar.  With 
stewed  fruits  and  puddings,  saccharin  may  be  used  in  small  amounts. 
I  have  many  children  taking  stewed  fruits,  cereals,  and  puddings  with- 
out a  particle  of  a  sweetening  agent.  Puddings  and  junket  are  to  be 
made  with  skimmed  milk.  The  fat  in  the  egg-yolk  is  particularly 
toxic  to  some  of  these  children,  particularly  those  who  have  cyclic 
vomiting.  Egg-yolks  are  accordingly  not  used  in  puddings.  When 
one  whole  egg  would  ordinarily  be  used,  the  whites  of  two  eggs  are 
used  instead.     A  custard  may  be  made  as  follows: 

White  of  one  egg. 
Saccharin. 

One-third  cup  scalded  skimmed  milk. 
10  drops  of  vanilla. 
10  grains  salt. 

Stir  white  of  egg  with  silver  fork.     Add  milk  gradually,  salt,  and  flavor- 
ing.    Strain  and  bake  somewhat  longer  than  for  ordinary  custard. 

In  many  instances  I  have  seen  rheumatic  children  suffering  from 
some  one  or  more  of  the  above-mentioned  conditions,  together  wdth 
anemia  and  a  stationary  weight,  coated  tongue,  and  loss  of  appetite, 
make  astonishing  gain  without  other  treatment  when  the  sugar  and 
cow  's-milk  fat  were  removed  from  the  diet.  Three  meals  a  day  should 
be  given.  A  free  daily  bowel  evacuation  is  to  be  provided  for  if  consti- 
pation is  a  feature  (p.  237). 

If  there  is  much  malnutrition,  the  scheme  of  living,  as  suggested  in 
tardy  malnutrition,  is  carried  out  (p.  100). 

The  Bath. — The  child  should  be  given  a  bath  at  bedtime,  followed 
by  a  cold  splash  or  douche.  After  the  bath,  while  the  feet  remain  in 
the  warm  water,  a  quart  or  two  of  cold  water  should  be  thrown  over  the 
body.  The  degree  of  cold  may  vary — 80°F.  to  70°F.  at  first;  after  a 
week  or  two  water  as  it  runs  from  the  faucet  may  be  used,  regardless 
of  the  season,  if  the  child  enjoys  it.  After  the  cool  douche  the  patient 
should  be  vigorously  rubbed  with  a  bath-towel  and  put  to  bed. 

Drugs. — The  only  drug  necessary,  other  than  perhaps  an  appetizer 
or  a  laxative,  is  bicarbonate  of  soda,  which  should  be  given  in  inter- 
rupted dosage — from  15  to  30  grains,  three  times  daily,  depending  upon 
the  age  and  requirement.  The  soda  is  to  be  given  after  meals  for  ten 
days,  with  a  free  interval  for  five  or  ten  days,  when  it  may  be  resumed. 
After  a  period  of  a  few  weeks  the  soda  may  be  discontinued,  but  the 
diet  must  be  kept  up  indefinitely.  These  children  cannot  bear  alcohol, 
and  it  should  not  be  included  in  their  tonic  or  restorative  medication. 
When  there  is  a  high  degree  of  systemic  poisoning  which  resists  the 
above  measures,  sodium  salicylate — rarely  more  than  5  grains — should 
be  given  three  times  a  day,  after  the  interval  method,  with  the  bicarbon- 


712  THE    PRACTICE    OF    PEDIATRICS 

ate  of  soda.     True  salicylate,  that  made  from  wintergreen  oil,  should 
always  be  advised. 

All  the  measures  suggested,  without  the  withdrawal  of  sugar  and 
free  fat  largely  from  the  diet,  are  of  little  avail. 

Illustrative  Cases. — Case  1. — A  case  which  is  characteristic  of  many  was  that  of 
a  boy,  two  and  one-half  years  of  age,  a  scion  of  one  of  America's  most  noted  famiUes. 
When  the  boy  came  under  my  care  he  was  having  periodic  attacks  of  catarrhal  colds, 
associated  with  cyclic  vomiting.  The  attacks  would  last  for  two  or  three  days  and 
were  not  very  severe.  There  was  rarely  fever.  He  had  been  treated  for  these 
repeated  colds  by  different  physicians  with  expectorant  drugs  and  local  chest 
applications,  all  of  which,  as  might  be  expected,  were  without  effect.  He  was  given 
the  dietetic  and  drug  management,  as  indicated  above;  and  notwithstanding  the 
fact  that  there  had  been  attacks  every  fourteen  days,  there  has  been  but  one  attack 
in  the  two  years  under  treatment.  First  cousins  of  the  child  have  habitual  colds 
with  spasmodic  bronchitis. 

Case  2. — A  most  remarkable  case  was  that  of  a  girl  who  came  under  my  care  in 
early  infancy  for  an  intense  and  obstinate  eczema.  From  this  she  recovered,  and 
when  one  year  of  age  developed  cyclic  vomiting.  During  the  next  two  years  there 
were  frequent  attacks  of  cyclic  vomiting,  spasmodic  laryngitis,  and  bronchial 
asthma.     The  association  of  these  conditions  has  been  previously  referred  to. 

Recurrent  Bronchitis. — Asthmatic  bronchitis  is  often  dependent 
upon  the  rheumatic  state,  and  repeated  attacks  suggest  the  degree  of 
the  vice  of  constitution. 

Illustrative  Cases. — Case  1. — A  girl  eight  years  old  came  under  my  care  because 
of  repeated  attacks  of  bronchitis.  The  mother,  a  woman  of  unusual  education 
and  refinement,  stated  that  the  child  had  had  an  average  of  two  attacks  of  bron- 
chitis monthly  during  the  previous  year,  and  at  least  one  attack  every  month  since 
she  was  five  years  of  age.  On  my  expressing  some  doubt  as  to  the  frequency,  the 
mother  stoutly  maintained  that  her  statement  was  correct.  The  family  lived  in 
Brooklyn,  and  had  been  told  that  the  child  could  not  remain  there  during  any  por- 
tion of  the  year.  She  had  spent  the  colder  months  at  different  winter  resorts,  with 
very  little,  if  any,  resultant  effect  upon  the  severity  or  frequency  of  the  attacks. 
The  child  was  pale  and  inclined  to  be  overstout.  There  had  been  no  other  illness 
of  consequence.  The  attacks  were  peculiar  in  that  they  were  of  short  duration, 
but  very  severe.  There  was  usually  a  temperature  range  from  100°  to  101°F., 
associated  with  cough,  difficulty  in  breathing,  and  occasional  attacks  of  marked  air- 
hunger.  The  attacks  were  always  accompanied  by  severe  coryza.  The  patient 
came  to  me  at  the  end  of  an  attack.  An  examination  of  the  chest  showed  through- 
out a  fairly  even  distribution  of  mucous  rales  involving  the  smaller  tubes.  Aside 
from  the  bronchitis  and  secondary  anemia,  the  examination  was  negative.  The 
child  had  attended  school  at  irregular  intervals,  but  only  for  a  few  weeks  of  her 
life.  While  getting  the  history  I  asked,  as  a  matter  of  routine,  if  the  child  snored  or 
if  she  were  a  mouth-breather.  This  caused  the  mother  to  remark  that  the  child 
had  been  under  the  care  of  throat  specialists  at  different  times,  and  each  physician 
had  removed  a  set  of  tonsils  and  a  set  of  adenoids!  The  mother  did  not  think  that 
there  was  very  much  left.  There  was  no  sign  of  a  tonsil  and  the  nasopharynx  was 
free.  In  spite  of  a  normal  rhinopharynx,  the  colds  had  continued.  In  taking  the 
history  I  had  learned  that  the  family  was  rheumatic  on  both  sides  for  at  least  three 
generations.  The  mother  claimed  to  have  suffered  a  great  deal  from  rheumatism. 
In  getting  the  personal  history  I  asked  if  the  child  was  fond  of  red  meat.  The 
reply  was  that  she  lived  on  it,  and  cared  for  little  else,  with  the  exception  of  sugar. 
Here  was  a  girl,  eight  years  of  age,  who  would  not  drink  milk  until  sugar  had 
been  added  to  it.  Cereals,  stewed  and  raw  fruits  were  loaded  down  with  sugar 
before  she  would  touch  them. 

In  my  instructions  as  to  the  treatment,  red  meat  was  allowed  once  every 
second  day  and  sugar  was  reduced  to  a  minimum — probably  not  more  than  one- 
fifth  the  usual  amount  being  given.  The  child  was  to  be  bribed,  if  necessary,  to 
eat  green  vegetables,  cereals,  and  fruits.  Expectorant  and  cough  mixtures  were 
discontinued.  She  was  given  20  grains  of  the  bicarbonate  of  soda  and  20  grains  of 
the  salicylate  of  soda  daily  for  three  weeks.  Later  the  drug  treatment  was  con- 
tinued at  intervals  during  the  remainder  of  the  winter.     She  passed  through  the 


ACIDOSIS  713 

following  winter  without  a  sign  of  rhinitis,  bronchitis,  or  asthma,  although  she 
continued  to  live  in  Brooklyn. 

Case  2. — Another  case  somewhat  similar  was  sent  to  me  by  a  well-known  rhin- 
ologist.  The  patient,  a  girl  seven  years  old,  had  suffered  from  repeated  attacks  of 
bronchitis  and  asthma  and  had  been  confined  to  her  home  a  greater  part  of  each 
winter.  Her  general  condition  was  thoroughly  wretched.  Her  family  physician 
had  attributed  the  condition  to  enlarged  tonsils  and  adenoids,  and  the  child  had 
been  sent  to  New  York  for  operation.  The  operation  was  performed,  and  the 
child  returned  to  her  home.  As  a  result  the  patient  could  breathe  easier  and  sleep 
better,  and  suffered  much  less  during  her  attacks  of  asthmatic  bronchitis;  but  the 
frequency  of  the  attacks  was  in  no  way  affected.  Early  the  following  summer  the 
patient  was  again  taken  to  the  rhinologist,  who,  finding  the  condition  of  the  upper 
respiratory  tract  satisfactory,  asked  me  to  take  charge  of  the  case,  remarking  that 
he  had  "cut  everything  in  sight  and  out  of  sight!"  The  treatment  outlined  above 
was  instituted,  and  while  the  results  were  not  so  flattering,  the  condition  was 
much  improved;  only  three  attacks  occurred  during  the  next  twelve  months,  and 
the  child  gained  15  pounds  in  weight. 

Repeated  inflammatory  involvement  of  the  mucous  membrane  of  the  upper 
respiratory  tract  in  children,  particularly  in  the  absence  of  enlarged  tonsils  and 
adenoids,  strongly  suggests  a  rheumatic  element  as  a  prominent  causative  factor. 

There  are  other  conditions,  apparently  of  rheumatic  origin,  which  are  not 
associated  particularly  with  the  common  manifestations. 

Rheumatic  Pleurisy. — Of  this  I  have  seen  four  cases.  There  was  no  pneu- 
monia and  no  lung  involvement  of  any  nature.  The  fluid  was  sterile,  and  the 
patients  never,  in  the  years  under  observation,  had  further  lung  signs.  The 
amount  of  fluid  in  each  case  was  large.  All  the  patients  came  for  treatment 
because  of  interference  with  respiration.  If  there  had  been  fever,  it  had  in  each 
instance  subsided  before  the  case  came  under  observation.  There  was  no  pain  and 
no  evidence  of  discomfort  other  than  the  cyanosis  caused  by  pressure. 

In  two  of  the  cases  there  was  a  distinct  history  of  rheumatism.  These  children 
were  between  two  and  six  years  of  age. 

Treatment. — The  diet  was  given  as  outlined,  with  salicylate  and  bicarbonate 
of  soda  in  dosage  suitable  for  the  age,  with  the  result  that  in  all  the  patients  there 
was  a  complete  absorption  of  the  fluid  in  less  than  a  week. 

Peliosis  Rheumatica. — In  this  unusual  affection,  which  appears  to  be  of 
rheumatic  origin,  purpura  isa  prominent  symptom.  In  my  patients  the  purpuric 
area  has  always  been  over  the  anterior  portion  of  the  lower  extremities,  and  in 
every  instance  the  disease  has  occurred  in  a  patient  who  had  had  previous  attacks 
of  rheumatism  or  chorea,  or  in  whom  the  rheumatic  element  was  prominent,  as 
shown  by  recurrent  tonsillitis  or  recurrent  bronchitis.  A  further  proof  of  the 
rheumatic  origin  of  the  disease  is  the  fact  that  the  cases  usually  yield  readily  to 
treatment  for  rheumatism. 

Treatment. — In  one  of  my  patients  there  were  two  distinct  attacks,  both  of 
which  yielded  fairly  well  to  the  salicylate  of  soda  and  the  iodid  of  potassium. 
The  medication  and  diet  are  the  same  as  those  suggested  for  rheumatism.  In 
case  erythema  nodosum  accompanies  the  condition,  local  measures  for  the  relief  of 
pain  (p.  590)  will  be  necessary. 

ACIDOSIS 

Acidosis  is  a  condition  in  which  there  is  a  diminution  of  the  alkaU 
reserve  of  the  body  fluids  especially  of  the  blood,  usually  attended  by 
an  excessive  formation  of  acids  with  its  resulting  clinical  symptoms. 

Etiology. — An  alteration  of  the  equilibrium  and  normal  relationship 
of  the  alkalies  and  acids  in  the  body  is  the  direct  exciting  cause.  The 
blood,  in  order  for  life  to  exist  must  be  maintained  at  a  very  constant 
reaction  which  is  slightly  alkaline,  and  there  must  be,  within  narrow 
limits,  a  certain  excess  of  bases  over  acids.  Any  change  from  the 
normal  toward  the  side  of  acidity  tends  to  inhibit  numerous  sensitive 
metabolic  processes  in  the  organism,  and  acidosis  results. 

Pathology. — Metabolic  products,  especially  carbonic  acid  are  con- 
stantly being  formed  in  the  tissues  and  poured  into  the  blood  to  be 


714  THE    PRACTICE    OF    PEDIATRICS 

transferred  to  the  lungs  for  elimination.  This  would  tend  to  alter  its 
normal  slightly  alkaline  reaction  to  one  strongly  acid  were  it  not  for  the 
alkaline  reserve  formed  by  bicarbonates  both  in  the  blood  and  tissues, 
the  alkaline  phosphates  of  sodium  and  potassium  and  the  alkali  pro- 
teins, in  conjunction  with  efforts  of  elimination  by  the  body.  The 
slightest  change  in  the  direction  of  acidity  is  sufficient  to  stimulate  the 
respiratory  center  through  the  agency  of  the  carbon  dioxid  contained 
in  the  blood.  The  increased  pulmonary  ventilation  removes  the  excess 
of  carbon  dioxid  and  the  blood  returns  to  its  original  state,  as  the  res- 
pirations lower  the  concentration  of  carbon  dioxid  in  the  lungs  and  thus 
allows  it  to  pass  from  the  tissues  where  it  is  in  greatest  tension  to  the 
blood  and  thus  to  the  lungs  where  the  tension  is  lowest.  Certain  non- 
volatile acids  as  sulphuric  and  phosphoric,  also  cause,  when  formed, 
increased  pulmonary  ventilation  and  hyperpnea,  as  they  remove  some 
of  the  alkaline  reserve  of  the  blood,  thus  leaving  more  of  the  carbonic 
acid,  normally  produced  by  the  tissues,  to  be  eliminated  through  the 
lungs.  These  acids  are  for  the  most  part  eliminated  through  the  kid- 
neys which  have  the  power  to  excrete  an  acid  urine  from  a  practically 
neutral  fluid,  leaving  behind  an  alkali  reserve  for  further  neutralization 
purposes.  An  interference  with  the  elimination  of  acids  as  well  as  their 
over-production  may  therefore  cause  acidosis.  A  final  and  very 
efficient  means  of  preserving  the  alkaline  balance  lies  in  the  ability  of 
the  body  to  form  the  alkali,  ammonia,  from  urea  a  neutral  substance, 
which  thus  adds  greatly  to  the  alkali  reserve. 

Symptoms. — Acute  acidosis  in  children  usually  manifests  itself  in 
two  ways,  a  'peculiar  symptom  complex,  seen  in  infants  and  in  recurrent 
or  so-called  cylic  vomiting  in  older  children.  In  the  former,  hyperpnea 
is  one  of  the  earliest  and  most  constant  symptoms.  The  majority  of 
cases  occur  in  infants  who  are  of  the  marasmic  type,  or  suffer  from  mal- 
nutrition and  who  have  finally  a  severe  attack  of  diarrhea,  following  a 
digestive  disturbance.  The  hyperpnea  is  associated  with  an  ashen 
gray  color  of  the  skin  and  a  peculiar  pallor  but  no  cyanosis.  At  first 
there  is  great  irritability  and  restlessness  which  is  succeeded  by  a  con- 
dition of  stupor  and  eventually  coma.  The  eyes  become  deeply  sunken 
and  staring,  the  mouth  and  lips  dry  and  parched,  the  fontanelle  is  de- 
pressed and  the  respirations  are  of  a  deep  and  sighing  character,  with- 
out pause  and  usually  labored.  On  being  aroused  from  the  stuporous 
state  marked  irritability  is  present,  the  cry  sounding  as  though  in  pain. 
The  temperature  curve  shows  marked  fluctuations,  not  usually  going 
above  101. 5°F.  A  polymorphonuclear  leukocytosis  ranging  from 
10,000  to  20,000  is  found.  A  very  scanty  secretion  of  urine  often 
amounting  to  anuria  is  frequent.  The  stools  are  usually  abundant  and 
of  a  watery  consistency.  Determinations  upon  the  expired  or  alveolar 
air  show  a  marked  reduction  in  the  carbon  dioxid  tension  which  may 
fall  as  low  as  12  to  15  mm.  of  mercury  from  the  normal  of  35  to  45 
mm.  There  is  a  great  tolerance  for  alkalies,  as  much  as  five  to  ten  times 
the  usual  amount  being  needed  to  bring  about  an  alkaline  reaction  of 


ACIDOSIS  715 

the  urine  to  litmus,  and  keep  it  alkaline  for  12  or  more  hours.  Acetone 
is  not  usually  found  in  the  urine  even  in  the  most  severe  cases. 

Treatment. — Alkalies  must  be  given  promptly,  and  in  sufficient 
quantities  to  bring  the  blood  back  to  the  normal  reaction.  Sodium 
bicarbonate  answers  the  purpose  best.  A  4  per  cent,  solution  for  intra- 
venous use  best  answers  the  purpose  especially  where  rapidity  of 
action  is  desired,  and  should  be  given  in  amounts  of  75  to  150  c.c. 
depending  on  the  age  of  the  infant.  This  may  be  repeated  in  3  to  4 
hours  if  the  hyperpnea  has  not  disappeared.  The  superior  longitu- 
dinal sinus  in  infants  offers  a  very  convenient  avenue  of  administra- 
tion or  the  external  jugular  veins.  In  older  children  the  median 
basilic  may  be  used.  Soda  in  doses  of  20  to  60  grains  should  be  given 
by  the  mouth  every  two  hours  until  the  urine  is  alkaline  to  litmus. 

As  the  activity  of  the  kidneys  is  at  a  low  ebb  when  acidosis  develops, 
they  should  be  stimulated  by  water  or  salt  solution  given  freely  by 
mouth,  rectum,  subcutaneously  or  intravenously.  (For  transfusion 
of  citrated  human  blood  in  acidosis  see  p.  786.) 

Cyclic  Vomiting  (Recurrent  or  Periodic  Vomiting) 

True  cyclic  vomiting  or  recurrent  vomiting  is  one  of  the  manifesta- 
tions of  acidosis,  p.  714.  Children  who  suffer  from  dilatation  and 
ptosis  of  the  stomach  (p.  177)  often  suffer  from  periodic  vomiting, 
likewise  those  who  have  mechanical  intestinal  defects  (p.  208)  and 
chronic  appendicitis.  In  these  cases,  however,  the  seizure  is  not 
prolonged  and  there  is  no  air  hunger,  no  great  prostration,  and  no 
fatalities. 

There  may  be  acetonuria  as  there  is  in  any  other  acute  disorder  in 
children,  without  diminished  alveolar  air  tension.  The  nature  of  the 
seizure  is  quite  apart  from  the  vomiting  of  acidosis. 

Etiology. — Children  who  have  cyclic  vomiting  often  show  varying 
nervous  phenomena,  such  as  habit  spasm,  chorea,  recurrent  spasmodic 
croup,  and  spasmodic  bronchitis.  Rachford  was  the  first  to  designate 
the  underlying  condition  as  a  gastrointestinal  lithemia. 

Secondary  Etiologic  Factors. — There  are  certain  associated  conditions 
which  may  precipitate  an  attack  in  a  susceptible  subject.  Habitual 
constipation  with  the  defective  elimination  is  present  in  some  cases. 
In  other  cases  there  is  an  associated  intestinal  crisis,  with  vomiting, 
high  fever,  and  a  sharp  diarrhea.  In  others  the  onset  may  usher  in  a 
pneumonia  or  one  of  the  exanthemata.  Fright  and  fatigue  and 
unusual  excitement  may  play  a  part  in  inducing  an  immediate  attack. 
Each  of  these  factors,  however,  represents  the  spark  that  ignites  the 
powder.  If  the  condition  of  systemic  intoxication  did  not  exist,  any  of 
the  influences  mentioned  would  not  produce  the  vomiting.  Recently 
Runyon  reported  six  cases  of  recurrent  vomiting  cured  by  the  removal 
of  a  chronically  diseased  appendix. 

There  are  also  seasonal  influences.  When  the  child  can  exercise  and 
perspire,  when  he  runs  much  and  plays  hard,  ehmination  is  better,  and 


716  THE    PRACTICE    OF    PEDIATRICS 

in  many  cases  fewer  attacks  occur.  Repeatedly,  in  getting  the  history 
of  these  cases  I  have  heard  that  there  are  no  attacks  between  May  and 
October. 

Symptoms. — The  vomiting  periods  occur  periodically.  I  have  had 
cases  in  which  the  attacks  occured  every  nine  days,  and  others  in  which 
they  occurred  but  once  in  three  or  four  weeks,  or  as  many  or  more 
months.  Each  patient  involuntarily  arranges  his  own  distinct  periods, 
and  he  usually  fulfils  the  contract. 

Prodromal  symptoms  have  been  unusual.  Now  and  then  a  mother 
will  state  that  she  can  anticipate  an  attack  by  some  peculiar  behavior 
on  the  part  of  the  child — that  he  will  lose  his  appetite  or  that  the  skin 
over  the  face  will  have  a  greenish  or  yellowish  tint,  or  that  the  breath 
will  be  offensive. 

The  symptoms  are  very  characteristic,  and  occur  in  no  other  condi- 
tion. The  child,  without  prodromal  signs,  has  a  sharp  attack  of  nau- 
sea and  vomiting.  The  nausea  is  extreme;  the  retching  and  straining 
at  emesis  occur  at  frequent  intervals.  There  is  often  no  elevation  of 
the  temperature.  There  may  be,  however,  decided  pyrexia  early  in 
the  attack.  In  Rachford's  experience  an  elevation  of  temperature  is 
the  rule  in  young  children.  There  is  marked  prostration.  The  child 
becomes  very  pale.  The  eyes  are  sunken,  and  the  loss  in  weight  is  rapid. 
Acetone  bodies  are  present  in  the  urine.  Neither  food  nor  water  is 
retained.  The  thirst  is  extreme.  In  all  there  is  exaggerated  sighing 
respiration,  a  true  air-hunger.  The  patients  beg  for  water,  only  to 
vomit  it  as  soon  as  it  is  given.  The  vomited  material  usually  contains 
hydrochloric  acid,  while  in  true  gastritis  free  hydrochloric  acid  is  absent 
(Rachford). 

The  illness  may  last  but  a  few  hours,  with  one  or  two  vomiting 
seizures.  In  the  average  case  the  duration  is  from  three  to  five  days. 
My  longest  case  was  in  a  boy  of  three  years  who  vomited  persistently  for 
thirteen  days.  In  some  cases  the  vomiting  is  sufficiently  severe  to  pro- 
duce hematemesis.  A  girl  of  eight  years  during  an  attack  vomited  such 
large  amounts  of  blood  that  it  was  necessary  to  keep  her  under  the  in- 
fluence of  morphin  given  hypodermatically. 

The  Breath. — During  the  attack  the  breath  usually  has  the  charac- 
teristic odor  of  acetone.  This  is  a  sweetish  odor,  not  unlike  that  of 
chloroform.  I  have  had  observant  mothers,  in  describing  the  child's 
symptoms,  refer  to  this  sign  without  suggestion  on  my  part.  An  exami- 
nation of  the  organs  and  the  secretions  fails  to  show  anything  abnormal 
excepting  the  presence  of  acetone,  diacetic  acid,  and  oxy butyric  acid  in 
the  urine,  as  described  by  Edsall. 

In  a  mild  or  moderately  severe  case  the  vomiting  stops  abruptly  and 
the  child  asks  for  food  and  retains  it,  providing  reasonably  simple  food 
is  given.  In  a  few  days  he  has  made  up  the  loss  in  nutrition  and  is  as 
well  as  ever. 

In  more  severe  attacks  the  child  may  require  several  days  to  regain 
his  usual  health  and  vigor.  The  resumption  of  the  feeding  will  neces- 
sitate considerable  care. 


ACIDOSIS  717 

Differential  Diagnosis. — A  first  attack  of  cyclic  vomiting  may  be 
confused  with  meningitis,  acute  indigestion,  or  the  vomiting  in  acute 
nephritis,  appendicitis,  or  intestinal  obstruction.  In  the  event  of  an 
abrupt  onset  in  a  first  attack  a  diagnosis  may  not  be  made  for  a  day 
or  two.  The  differentiation  laid  down  in  some  of  the  books  is  not 
dependable. 

Thus  the  vomiting  which  occurs  as  the  earliest  symptom  of 
tuberculous  meningitis  may  be  clinically  identical  with  that  of  cylic 
vomiting,  and  only  by  the  appearance  of  other  signs  of  meningitis  or 
through  lumbar  puncture  is  the  differentiation  possible. 

In  acute  indigestion  there  is  a  brief  period  of  fever  and  one  or  two 
vomiting  seizures,  after  which  the  case  is  well.  In  acute  nephritis  an 
examination  of  the  urine  readily  settles  the  diagnosis.  In  appendicitis 
there  is  pain  and  spasticity  and  the  vomiting  is  not  continuous ;  in 
cyclic  vomiting  the  abdomen  is  relaxed,  soft,  and  not  tender.  Intesti- 
nal obstruction  is  an  affection  of  infancy;  cyclic  vomiting  rarely  occurs 
before  the  second  year,  and  usually  not  until  after  the  third  year.  In  in- 
testinal obstruction,  moreover,  there  is  abdominal  distention  and  the 
passage  of  bloody  mucus,  due  to  intussusception. 

Prognosis. — The  prognosis  is  usually  good  not  only  as  regards  life, 
but  as  regards  the  continuation  of  the  attacks.  I  have  seen  six  fatal 
cases. 

Treatment. — Treatment  in  the  Interval. — In  describing  the  manage- 
ment of  children  who  show  the  rheumatic  complex,  the  influence  of  the 
intense  carbohydrates  and  fat  was  referred  to.  In  the  cyclic  vomiting 
cases  the  precaution  of  witholding  these  substances  from  the  diet  is  one 
of  the  most  necessary  features  of  the  interval  management.  Different 
authors  refer  to  the  fact  that  the  use  of  milk  in  some  children  is  produc- 
tive of  attacks.  It  is  the  fat  content  of  the  milk  that  produces  the  at- 
tack. These  patients  may  take  fat-free  milk  and  buttermilk  without 
inconvenience.  The  diet  prescribed  for  the  cyclic  vomiting  case  is 
that  laid  down  on  p.  710. 

Milk-fat,  sugar,  and  egg-yolks  are  forbidden.  Red  meat  maj''  be 
given  only  in  small  amounts. 

Medication. — For  a  child  from  three  to  ten  years  of  age  from  9  to  12 
grains  of  wintergreen,  salicylate  of  soda,  or  aspirin  are  to  be  given  after 
meals  daily  in  divided  doses,  for  five  days  out  of  fifteen.  During  the 
ten  days  of  rest  from  the  salicylates  10  grains  of  bicarbonate  of  soda 
should  be  given  twice  daily  after  meals.  This  method  of  treatment 
must  be  continued  for  months.  If  the  salicylate  of  soda  interferes  with 
digestion  or  with  the  appetite,  aspirin  in  equal  dosage  may  be  substi- 
tuted. Under  this  method  of  treatment  in  cases  in  which  attacks  had 
been  occurring  every  month  or  six  weeks  the  intervals  have  been  in- 
creased to  six  months  or  a  year,  and  in  many  cases  the  attacks  have 
entirely  ceased.  Spasmodic  treatment  is  of  little  value ;  onl}^  persistent 
treatment  is  effective,  and  there  must  be  confidence  and  cooperation 
on  the  part  of  the  family  or  any  treatment  will  fail. 

An  important  requirement  in  the  management  is  that  the  patient 


718  THE    PRACTICE    OF    PEDIATRICS 

live  a  normal  child's  life.  There  should  be  a  suitable  rest  period  after 
the  midday  meal.  Three  meals  are  to  be  given  daily,  and  there  must 
be  one  free  bowel  evacuation  daily  without  the  habitual  use  of  enemata. 
A  free  green  vegetable  diet  with  stewed  fruit  will  do  much  to  accom- 
plish this.     (See  Constipation,  p.  236.) 

Treatment  of  the  Acute  Attack. — All  food  should  be  withheld.  Hot 
bicarbonate  of  soda  water,  10  grains  in  3  to  4  ounces  of  water,  should  be 
given  every  hour  if  possible.  If  it  is  vomited,  one  teaspoonful  of  the 
solution  is  to  be  given  at  a  time.  If  this  or  plain  water  is  ejected,  the 
stomach  must  be  allowed  to  rest.  Medication  other  than  the  bicar- 
bonate of  soda  should  not  be  attempted.  After  twenty-four  hours, 
with  a  continuation  of  the  vomiting,  a  colon  flushing  (p.  793)  with  & 
ounces  of  warm  water  containing  2  drams  of  bicarbonate  of  soda  may 
be  employed.  This  should  be  repeated  at  six-  to  eight-hour  intervals. 
It  is  astonishing  to  note  how  much  of  this  solution  will  be  taken  up  if 
the  tube  is  introduced  well  into  the  colon. 

Repeatedly  I  have  known  patients  to  retain  two  pints  a  day.  The 
procedure  supplies  fluid,  relieves  thirst,  and  prevents  prostration  and 
loss  in  weight.  At  the  same  time  the  bicarbonate  of  soda  furnishes  the 
best  antidote  to  the  acid  intoxication  that  exists.  If  the  colonic  medi- 
cation is  not  well  retained,  it  should  be  used  but  twice  daily,  so  as  not  to 
establish  an  intolerance.  Discretion  must  be  used  in  giving  food. 
Some  children  will  have  a  disgust  for  all  foods,  and  others  will  be  as 
hungry  as  they  are  thirsty.  This,  however,  is  unusual.  I  have  known 
these  children  to  retain  twice-baked  bread  and  unsweetened  zwieback 
when  nothing  else  could  be  kept  down.  Further,  when  the  vomiting 
ceases  and  the  child  is  on  the  borderland  of  convalescence,  some  one  of 
the  dried  bread-stuffs  often  answers  better  than  does  a  fluid  diet.  In  a 
general  way,  however,  a  diet  of  broth,  gruel,  skimmed  milk,  and  dried 
bread  is  best  for  the  first  few  days  following  an  attack. 

If  the  cases  prove  resistant  and  but  little  of  the  bicarbonate  is  re- 
tained, a  2  per  cent,  solution  of  the  chemically  pure  drug  may  be  given  ^ 
intravenously — from  60  to  80  grams  may  be  introduced  in  this  way. 
The  solution  may  be  used  plain  or  in  combination  with  4  per  cent, 
chemically  pure  dextrose.  Hypodermoclysis  gives  another  means  of 
using  the  chemically  pure  drug  alone  or  in  combination  with  dextrose. 
A  4  per  cent,  solution  of  the  bicarbonate  and  dextrose  may  be  used 
in  this  way.  Whether  the  intravenous  or  hypodermoclysis  method  is 
selected,  the  procedure  may  be  repeated  in  twelve  hours. 

In  a  recent  case  of  severe  acidosis  seen  with  Dr.  Mosher,  of 
Brooklyn,  a  fatal  outcome  seemed  imminent.  Bicarbonate  of  soda 
freely  administered  and  two  transfusions  of  bicarbonate  of  soda  with 
four  per  cent,  dextrose,  given  intravenously  failed  to  produce  the 
slightest  improvement.  In  desperation  transfusion  of  human  blood 
was  decided  upon  and  six  ounces  of  citrated  blood  was  given.  The 
improvement  following  the  use  of  human  blood  was  most  remarkable. 
The  hyperpnea  ceased,  the  pulse  improved  and  the  entire  expression 
of  the  child  changed  in  a  very  few  hours.     The  boy  made  a  complete 


CYCLIC   DIAERHEA  719 

recovery,  all  traces  of  acidosis  disappearing  within  five  days  after  the 
transfusion. 

CYCXIC  DIARRHEA 

Excess  of  sugars  and  fat  in  the  diet  of  children  of  the  so-called 

lithemic  type  may  produce  characteristic  gastro-enteric  effects  entirely 

.  independent  of  intestinal  and  stomachic  conditions.     Patients  of  this 

;  type  represent  those  who  possess  a  poor  capacity  for  the  metabolism  of 

these  substances. 

Cases  of  this  kind  are  not  at  all  unusual,  and  are  usually  attributed 
to  errors  in  diet,  to  fatigue,  to  overexcitement  or  nervousness. 

Symptoms. — There  may  be  a  prodromal  period  of  a  few  days,  with 
foul  breath,  coated  tongue,  languor,  and  loss  of  appetite.  More  often 
the  onset  is  sudden  and  without  warning.  There  is  sudden  high 
fever,  headache,  vomiting,  diarrhea,  muscle  soreness,  and,  rarely, 
delirium.  Abdominal  pain  maybe  present,  colicky  in  character.  The 
fever  rarely  lasts  longer  than  two  or  three  days — often  not  longer  than 
one  day.  The  gastro-intestinal  manifestation  of  the  toxemia  may  per- 
sist for  a  shorter  or  longer  time.  Some  children  will  have  one  or  two 
vomiting  seizures;  others  none.  The  intestines,  however,  are  much  dis- 
turbed. Loose  watery  stools  are  frequent,  and  defecation  is  attended 
with  considerable  pain  and  tenesmus.  After  an  indefinite  period  of 
time — usually  one  to  three  days — the  symptoms  abruptly  subside,  and 
the  child  becomes  hungry  and  begs  for  more  food  than  is  good  for  him. 
Usually  after  such  an  attack  the  child  feels  unusually  well,  and  no 
evidence  of  the  seizure  remains.  In  the  course  of  a  few  weeks  the 
identical  process  is  repeated,  although  the  mother  volunteers  the  infor- 
mation that  the  child  has  been  carefully  fed  and  that  the  attacks  can- 
not be  attributed  to  indiscretion  in  diet.  Occasionally  such  cases  are 
associated  with  cyclic  vomiting. 

Illustrative  Case. — A  boy  six  years  of  age  almost  always — such  was  the  history 
— began  the  cyclic  vomiting  attack  with  the  symptoms  as  described.  Vomiting 
ordinarily  did  not  begin  until  the  fever  and  the  urgent  intestinal  symptoms  had 
subsided. 

The  attacks  are  quite  apt  to  be  followed  by  constipation.  These 
gastro-intestinal  crises  become  as  distinctly  periodic  as  those  of  cyclic 
vomiting  and  spasmodic  bronchitis.  I  have  treated  a  large  number  of 
these  patients  who  have  been  brought  solely  because  of  the  periodic 
attacks  which  are  referred  to  by  the  mother  or  nurse  as  "indigestion," 
"gastritis,"  or  "biliousness." 

If  the  attacks  are  frequent,  there  will  be  the  signs  of  malnutrition. 
Usually  the  patient  has  resistance  of  a  low  order  and  is  apt  to  be  nerv- 
ous and  pale.  The  muscles  are  flabby.  The  tongue  may  be  habitu- 
ally coated.  The  child  is  chronically  tired,  "or  never  quite  well." 
This  description  obtains  in  the  most  severe  cases.  Children,  however, 
who  undergo  the  periodic  attacks  at  intervals  of  several  weeks  suffer 
but  temporary  inconvenience.  The  acetone  breath  has  been  present 
during  the  attack  in  a  few  of  my  cases ;  its  occurrence  is  the  exception. 


720  THE    PRACTICE    OF   PEDIATRICS 

Illustrative  Cases. — Case  1. — A  girl,  three  years  of  age,  of  decidedly  gouty  ante- 
cedents in  both  parents,  had,  for  the  eighteen  months  previous  to  examination, 
attacks  of  "indigestion"  every  six  weeks.  There  was  no  vomiting.  The  tem- 
perature rarely  rose  above  103°F.  There  was  pronounced  diarrhea  with  little 
mucus.  At  each  attack  she  had  been  given  castor  oil  and  a  reduced  diet,  and  was 
well  in  four  or  five  days.  Between  the  attacks  she  was  fairly  well,  excepting  that 
the  tongue  was  never  clean  and  there  was  a  persistent  low-grade  eczema  on  the 
neck  and  upper  portion  of  the  chest,  which  had  resisted  the  treatment  of  different 
dermatologists.  The  child  had  been  fed  with  reasonable  care  under  medical 
direction.     There  had  been  no  gain  in  weight  during  the  year. 

She  was  given  a  mixed  diet  of  meat,  poultry,  fish,  green  vegetables,  and  cereals. 
One  pint  of  skimmed  milk  or  fat-free  buttermilk  was  allowed  daily.  Sugar  of  every 
kind  was  prohibited.  Raw  fruit  was  not  permitted.  Ten  grains  of  bicarbonate  of 
soda  were  given  daily  for  several  weeks.  During  the  twenty-one  months  of  treat- 
ment there  has  been  no  suggestion  of  the  former  trouble. 

Case  2. — A  boy  six  years  of  age  had  repeated  attacks  of  diarrhea  lasting  from 
two  to  ten  days.  The  majority  of  the  attacks  occurred  during  the  warmer  months, 
but  there  were  also  three  or  four  during  the  winter.  There  was  fever,  rarely 
higher  than  102°F.,  and  rarely  vomiting.  Dietetic  restrictions  as  regards  sugar 
and  fat  were  carried  out,  and  skimmed  milk  in  small  amount  was  allowed  during 
the  next  three  months, — July,  August,  and  September,* — a  period  during  which  he 
had  never  before  been  well.  He  now  remained  perfectly  well,  and  during  this 
time  gained  1^^  pounds  in  weight.     There  has  been  no  repetition  of  the  attacks. 

I  could  give  many  histories  of  cases  in  which  the  periodic  intestinal 
crises  were  relieved  by  the  withdrawal  of  fat  and  sugar  from  the  diet, 
and  by  the  free  use  of  bicarbonate  of  soda  for  protracted  periods. 
Starches  appear  to  exert  no  influence  on  the  condition.  Sugar  that  is 
manufactured  by  the  organism  exerts  no  unfavorable  influence. 

Treatment. — As  indicated,  the  treatment  consists  in  withdrawing 
fat  and  sugar  largely  from  the  diet,  and  in  the  use  of  bicarbonate  of 
soda.  If  constipation  is  present,  I  usually  give  30  grains  daily  with 
sufficient  aromatic  cascara  to  keep  the  bowels  active.  Stewed  fruit 
and  cereals  are  usually  readily  taken  without  sugar.  If  necessary, 
small  amounts  of  saccharin  may  be  used  for  sweetening.  Eating  be- 
tween meals  is  forbidden,  and  the  child  is  made  to  take  an  after-dinner 
rest  of  one  and  one-half  hours.     Stress  of  all  kind  is  avoided. 


PERIODIC  FEVER 

Febrile  cases  somewhat  resembling  the  above  are  of  unusual  occur- 
rence. The  clinical  condition  is  that  of  periodic  fever  without  another 
symptom. 

Illustrative  Cases. — Case  1. — The  temperature  in  one  of  my  cases,  aged  four 
years,  ranged  from  102°  to  103. 5°F.  and  lasted  four  to  six  days.  This  child  came 
to  me  because  of  the  periodic  elevation  of  temperature  which  could  not  be  ac- 
counted for.  During  his  third  year  there  were  six  of  these  temperature  periods. 
In  the  fourth  year  there  were  four,  all  during  January,  February,  and  March. 
There  was  no  gastro-intestinal  association  and  no  clinical  evidence  of  disease  to 
account  for  the  temperature  periods.  The  mother  stated  that  "the  breath  smelled 
like  chloroform"  during  the  attacks.  An  exhaustive  examination  failed  to  detect 
anything  wrong  with  the  child  other  than  a  persistent  erythema  at  the  angle  of  the 
mouth  on  the  right  side.  The  patient  was  given  a  diet  free  from  fat  and  sugar. 
Thirty  grains  of  bicarbonate  of  soda  were  given  daily.  Two  years  have  elapsed 
without  a  return  of  the  temperature  period. 

Case  2. — In  the  case  of  another  boy,  aged  six  years,  the  temperature  period 
persisted  two  to  five  days,  and  the  range  was  100°  to  104°F.     During  the  attack  the 


RHEUMATIC    FEVER    (aCUTE    RHEUMATISM)  721 

tongue  was  coated  and  the  patient  complained  of  being  very  tired.  The  attacks 
appeared  without  warning  and  disappeared  without  other  evidences  of  illness  than 
the  fever.  There  was  no  objective  gastro-intestinal  disturbance.  In  one  year 
there  were  five  temperature  periods;  during  the  next  year,  three. 

In  neither  of  these  cases  was  there  another  sign  of  trouble  than  the 
recurring  temperature;  the  children  had  been  treated  and  examined 
repeately  with  an  idea  to  determine  the  cause. 

In  all  I  have  had  six  examples  of  this  fever  phenomenon.  All  the 
patients  were  relieved  promptly  by  removing  sugar  and  cow's-milk  fat 
from  the  diet,  and  by  the  interval  use  of  bicarbonate  of  soda. 


RHEUMATIC  FEVER  (ACUTE  RHEUMATISM) 

Acute  rheumatism  is  a  rare  disease  in  young  children.  Conditions 
described  as  rheumatism  in  infants  and  children  under  two  years  are 
usually  scurvy  or  infectious  peri-arthritis.  The  latter  is  not  at  all  un- 
usual, and  the  possibilities  of  scurvy  are  always  with  us.  Among  1027 
cases  of  rheumatism.  Still  saw  none  under  two  years  of  age.  My  own 
cases  have  all  been  in  children  after  the  third  year.  The  majority  of 
the  cases  occur  between  the  fifth  and  ninth  years. 

It  is  a  mistake  to  designate  rheumatic  fever  as  "acute  articular 
rheumatism,"  as  we  see  many  cases  in  which  the  joint  symptoms  play  a 
slight  part,  or  no  part  at  all,  the  heart  bearing  the  brunt  of  the  attack. 
Repeatedly,  endocarditis  or  pericarditis  has  been  the  main  manifesta- 
tion of  the  disease. 

Illustrative  Cases. — Case  1. — A  boy  came  to  the  out-patient  service  at  the 
Babies'  Hospital  because  of  sore  throat  and  a  temperature  of  101°F.  There  was  a 
very  mild  tonsillitis,  and  for  one  night  there  had  been  pain  in  the  left  knee.  An 
examination  of  the  heart  showed  an  extensive  endocarditis  involving  both  the 
aortic  and  mitral  valves. 

Case  2. — A  girl,  four  years  old,  a  subject  to  periodic  colds  and  asthmatic 
bronchitis,  had  a  mild  seizure  of  this  nature,  requiring  that  she  remain  in  bed  for  a 
few  days.  While  examining  the  lungs  I  detected  a  soft  systolic  murmur.  Three 
days  later  pain  and  swelling  appeared  in  a  knee-joint.  A  polyarthritis  followed, 
involving  in  all  nine  joints.  In  this  child  the  heart  involvement  preceded  the  joint 
symptoms  several  days. 

It  is  not  at  all  unusual  to  see  endocarditis  in  the  offspring  of  the 
rheumatic,  without  the  previous  existence  of  a  painful  joint.  These 
cases,  however,  will  afford  the  history  of  chorea  or  recurrent  spasmodic 
bronchitis,  frequent  anginas,  periodic  gastric  or  intestinal  crises,  or 
growing  pains.  In  fact,  endocarditis  is  far  more  often  the  manifesta- 
tion of  acute  rheumatism  than  is  inflammation  of  the  joints. 

On  the  other  hand,  many  cases  are  seen  in  which  the  heart  remains 
free,  with  the  joint  involvement  of  a  most  urgent  nature. 

Etiology. — That  acute  rheumatism  is  a  manifestation  of  an  infecting 
agent  or  agencies  the  majority  of  the  profession  are  agreed.  It  will 
probably  be  demonstrated  that  more  than  one  infecting  agent  may 
cause  acute  rheumatism  in  a  child  predisposed  in  the  manner  that  I 
have  attempted  to  describe  in  the  previous  chapter.  Perhaps  it  will 
46 


722  THE    PRACTICE    OF    PEDIATRICS 

be  proved  that  both  bacterial  and  other  toxic  agents  may  cause  the 
disease. 

Symptoms. — (For  Endocarditis,  see  p.  379.)  Like  all  diseases  of  an 
infectious  origin,  acute  rheumatism  may  be  so  mild  as  to  escape  notice, 
or  it  may  be  most  severe.  In  the  joint  type  the  first  symptom  is  pain 
in  the  joint;  this  may  be  very  sHght,  or  it  may  be  most  intense — so  in- 
tense that  the  bed-clothing  may  not  touch  the  parts  without  increasing 
the  pain.  Between  these  two  extremes  there  are  all  degrees  of  involve- 
ment. There  may  be  neither  swelling  nor  redness,  or  the  swelling  may 
be  extreme,  with  marked  redness,  the  part  being  twice  as  large  as  its 
unin  vol  ved  fellow.  One  joint  or  several  maybe  affected.  The  pain 
and  swelling  usually  begin  in  one,  and  subsequently  affect  others.  The 
first  joint  to  become  inflamed  is  usually  the  first  one  in  which  the  in- 
flammation subsides. 

The  duration  of  the  attack  is  also  subject  to  much  variation — it  may 
last  but  a  few  days,  or  it  may  last  for  six  weeks  or  longer.  A  case  of 
average  severity  rarely  lasts  longer  than  two  to  three  weeks. 

There  may  be  no  temperature,  or  it  may  range  from  103°  to  105 °F., 
depending  entirely  upon  the  severity  of  the  infection. 

Prognosis. — The  prognosis  for  the  immediate  attack  in  articular 
rheumatism  is  good.  All  cases  recover  if  there  is  no  heart  involvement. 
When  there  has  been  one  attack,  however,  there  is  great  liability  of 
another,  and  parents  should  be  made  to  understand  this  feature  of  the 
disease.     In  the  second  seizure  the  heart  may  be  the  part  attacked. 

Precautions. — In  every  case  of  joint  rheumatism  the  heart  should 
be  examined  daily  for  evidence  of  endocarditis  and  pericarditis. 

Treatment. — General  Management. — Rest  in  bed  is  an  absolute 
necessity  even  in  the  milder  cases.  The  diet  of  the  patient  may  consist 
of  milk,  junket,  gruel,  toast,  stale  bread,  weak  tea,  stewed  fruit,  and 
orange-juice.  Vichy  and  lemonade  may  be  given  to  drink.  There 
should  be  one  evacuation  of  the  bowels  daily. 

Local  Measures. — Considerable  comfort  may  be  furnished  by  local 
measures,  which  will  permit  the  child  to  sleep,  resulting  in  a  much  im- 
proved food  capacity.  The  affected  joint  or  joints  should  be  comfort- 
ably supported  on  a  cushion  or  pillow,  and  the  parts  kept  well  protected 
by  cotton-wool  or  flannel  dressings.  The  U.  S.  P.  lead  and  opium 
solution  which  is  used  to  moisten  the  gauze  dressings  will  aid  in  reliev- 
ing the  pain.  The  joint  should  be  loosely  wrapped  in  strips  of  linen 
which  have  been  wet  with  the  warm  solution.  Over  this  should  be 
placed  oiled  silk  to  prevent  rapid  evaporation,  and  over  all  a  flannel 
bandage.  In  the  acute  cases  the  dressing  should  be  changed  every 
hour  until  the  pain  is  relieved.  This  can  readily  be  done  without  dis- 
turbing the  patient.  A  liniment  composed  of  menthol,  2  drams,  tinc- 
ture of  opium,  13-^  ounces,  and  enough  alcohol  to  make  6  ounces, 
applied  on  strips  of  linen  and  covered  with  oiled  silk,  is  another  local 
application  which  has  been  of  considerable  service  in  relieving  pain. 
The  dressing  should  be  renewed  every  two  or  three  hours  as  the  case 
requires. 


BHEUMATIC    FEVER    (aCUTE    RHEUMATISM)  723 

Drugs. — Various  drugs,  such  as  oil  of  wintergreen,  aspirin,  and  com- 
binations of  the  alkahs  with  the  sahcylates,  have  been  used  in  a  consid- 
erable number  of  cases.  The  most  effective  internal  medication  has 
been  the  bicarbonate  in  association  with  the  salicylate  of  soda.  The 
salicylate  must  be  given  in  large  doses.  Two  points,  however,  are  to 
be  kept  in  mind  in  the  use  of  large  doses  of  salicylate  in  children:  its 
depressing  effect  upon  the  heart,  and  the  tendency  to  produce  derange- 
ment of  digestion,  as  evidenced  by  nausea  and  vomiting.  The  salicy- 
late should  never  be  given  with  the  stomach  empty.  It  is  given  to  the 
best  advantage  after  meals,  and  always  in  solution.  For  a  child  five 
years  of  age,  the  following  may  be  prescribed: 

I^     Sodii  salicylatis 5ij 

Elix.  simplicis 5  iss 

Aquae q.  s.  ad  §  iv 

Sig. — One  teaspoonful  in  plain  water  or  in  Vichy  four  times  daily 
after  meals. 

There  are  about  24  teaspoonfuls  in  a  4-ounce  bottle.  The  average 
teaspoonful,  as  is  well  known,  holds  more  than  one  dram.  Computing 
24  doses  to  a  4-ounce  mixture,  we  give  this  five-year-old  patient  20 
grains  of  salicylate  of  soda  in  twenty-four  hours.  The  amount  may  be 
increased  to  30  grains  if  the  condition  is  serious.  Larger  doses  than  30 
grains  for  children  of  this  age  I  do  not  consider  safe,  as  I  have  seen  such 
doses  followed  by  irregularity  of  the  heart  action  and  cyanosis.  The 
average  child  from  eight  to  ten  years  of  age  will  take  30  grains  daily 
without  inconvenience.  At  the  third  year  I  have  given  from  12  to  .15 
grains  repeatedly,  with  most  satisfactory  results.  The  bicarbonate  of 
soda  may  be  given  in  combination  with  the  salicylate,  but  it  is  best 
given  alone  in  Vichy  or  carbonic  water  between  meals.  To  a  child 
five  years  old  or  under,  20  grains  should  be  given  in  twenty-four  hours. 
For  children  from  seven  to  ten  years  of  age,  30  to  40  grains  daily  is 
the  amount  required. 

The  dosage,  both  of  the  salicylate  and  of  the  bicarbonate  of  soda, 
should  gradually  be  reduced  as  the  condition  of  the  child  improves. 

Later  Treatment. — It  is  my  custom  never,  willingly,  to  let  a  child 
who  has  once  had  an  attack  of  acute  articular  rheumatism  disappear 
from  my  observation.  As  the  outcome  of  repeated  attacks,  endocar- 
ditis is  likely  to  develop  sooner  or  later.  After  one  attack  the  parents 
should  be  advised  as  to  the  probablity  of  a  recurrence,  and  its  dangers 
should  be  pointed  out  to  them.  They  should  be  instructed  to  keep  the 
child  on  a  low  meat  and  sugar  diet.  Sugar  is  to  be  given  only  in  suf- 
ficient quantity  to  make  the  food  palatable.  Five  days  out  of  every 
fifteen,  10  grains  of  the  salicylate  of  soda,  separately  or  combined  with 
10  grains  of  bicarbonate,  should  be  given  daily.  This  should  be  contin- 
ued for  six  months,  when  treatment  for  five  days  out  of  each  month  will 
suffice.     In  some  cases  I  have  continued  this  method  indefinitely. 

In  all  cases  of  acute  articular  rheumatism  in  children  the  tonsils 
and  adenoids  should  be  thoroughly  investigated  and  their  removal  ad- 


724  THE    PRACTICE    OF    PEDIATRICS 

vised  if  found  diseased.  Foci  of  infection  have  also  been  found  at 
the  root  of  the  teeth,  therefore  an  a;-ray  examination  of  the  teeth 
should  always  be  made. 

RHEUMATOID  ARTHRITIS;  ARTHRITIS  DEFORMANS; 
STILL'S  DISEASE 

Under  the  above  headings  may  be  noted  those  forms  of  chronic 
arthritis  which, occur  independently  of  ordinary  pyogenic  infection, 
gonorrhea,  syphilis,  tuberculosis,  rheumatism,  and  rachitis.  Attempts 
at  exact  differentiation  of  the  arthritides  of  this  class  rest  in  the  main 
upon  varying  clinical  manifestations  which  may  or  may  not  represent 
separate  and  distinct  disease  processes.  In  a  recent  reference  to  this 
subject  Rachford*  has  emphasized  three  types  of  *' rheumatoid  ar- 
thritis"— (1)  Chronic  arthritis  with  hypertrophic  changes  predominant; 
(2)  chronic  arthritis  with  atrophy  predominant;  (3)  Still's  disease. 

The  condition  last  named  is  sufficiently  striking  to  require  special 
attention,  and  the  points  emphasized  by  Still  are  here  mentioned. 

Still's  Disease. — The  specific  etiology  is  unknown.  The  disease  is 
quite  possibly  of  bacterial  origin.  Females  are  apparently  slightly 
predisposed.     Children  are  rarely  susceptible  after  the  sixth  year. 

The  morbid  anatomic  changes  comprise  thickening  and  vasculariza- 
tion of  synovial  membranes,  capsules,  and  ligaments  of  the  affected 
joints,  and,  in  advanced  cases,  moderate  atrophic  changes  in  the  carti- 
lage, with  perhaps  the  formation  of  adhesions.  Effusion  is  not  an  es- 
sential part  of  the  process.  Considerable  enlargment  of  the  lymphatic 
glands  and  spleen  is  a  constant  feature. 

Symptoms. — The  onset  is  usually  gradual,  but  may  be  acute,  with 
fever  and  chills.  Primary  stiffness  in  one  or  more  joints  is  succeeded 
by  progressive  joint  enlargement  without  bony  involvement,  ankylosis, 
or  suppuration.  The  knees,  wrists,  cervical  spine,  fingers,  ankles,  and 
toes  may  be  affected.  Active  and  passive  movements  are  restricted, 
and  eventually  atrophy  and  contracture  of  muscles  may  occur,  without, 
however,  impairment  of  electric  reactions.  The  lymphatic  glands  are 
enlarged,  particulary  those-related  to  the  affected  joints.  The  edge 
of  the  spleen  may  usually  be  found  below  the  costal  margin.  The 
blood  shows  a  moderate  anemia  and  occasionally  a  leukocytosis. 

Still's  disease  is  to  be  distinguished  from  rickets,  syphilis,  the 
various  forms  of  muscular  atrophy,  and  caries  of  the  cervical 
vertebrae. 

The  prognosis  is  not  favorable.  The  disease  is  not  directly 
fatal,  but  its  effects  are  crippling.     Koplik  reports  a  recovery. 

The  treatment  of  rheumatoid  arthritis  is  largely  symptomatic.  An 
even  climate,  free  from  excess  of  moisture,  is  desirable.  Anemia  and 
malnutrition  are  to  be  combated  in  the  usual  manner.  Massage  and 
suitable  applications  may  influence  the  local  conditions  favorably.     In 

*"  Diseases  of  Children,"   B.  K.  Rachford. 


CHONDRODYSTROPHIA  (ACHONDROPLASIA)         725 

view  of  the  possible  influence  of  latent  foci  of  infection  upon  the  devel- 
opment of  the  disease,  oral  sepsis  and  intestinal  putrefaction,  espe- 
cially, must  be  prevented.     Pituitary  extract  is  of  possible  value. 

CHONDRODYSTROPHIA  ( ACHONDROPLASIA) 

Achondroplasia  is  a  disease  of  fetal  life  characterized  chiefly  by  de- 
fective development  of  the  long  bones. 

The  terms  applied  to  this  disease  constitute  a  long  list.  Some  of 
these  are  "fetal  rickets,"  "micromeha,"  "chondromalacia,"  "fetal 
chondritis,"  and  "  chondrodystrophia  foetalis." 

Emerson,  writing  in  Osier's  "Modern  Medicine,"  cites  many  ex- 
amples from  Egyptian,  Grecian,  and  medieval  art,  which  go  to  prove 
the  antiquity  of  this  disease.  He  further  states  that  of  all  dwarfs, 
those  with  this  affection  have  been  most  popular  in  the  positions  of 
court  clowns  and  jesters.  The  condition  has  long  been  confused  with 
rickets,  cretinism,  and  certain  types  of  syphilis.  Parrot  first  made 
clear  the  pathologic  distinctions  in  1878,  and  Porak  gave  a  very  full 
account  of  the  subject  in  1899. 

Etiology. — Heredity  is  an  influential  but  not  apparently  an  un- 
failing factor.  In  many  instances  there  is  no  family  history  of  a  sig- 
nificant character.  Emerson  suggests  that  achondroplasia  and  rick- 
ets may  be  related,  in  spite  of  the  usual  variance  in  their  manifestations 
and  the  evidence  against  the  occurrence  of  so-called  intra-uterine 
rickets.  By  many  achondroplasia  is  thought  to  be  due  to  defective 
function  in  one  or  more  of  the  glands  of  internal  secretion.  Syphilis 
is  sometimes  associated  with  this  affection,  but  cannot  be  said  to  be 
a  cause. 

Pathology. — The  lesions  are  localized  in  the  bones,  more  particu- 
larly the  long  bones  and  those  of  the  base  of  the  skull.  The  epiphyses 
are  primarily  affected.  Here  there  is  always  defective  formation  of 
cartilage,  whence  the  descriptive  name,  chondrodystrophy.  Periosteal 
growth  goes  on,  and,  by  invading  the  region  which  is  normally  sup- 
plied with  bone  by  the  cartilage-cells,  impairs  still  more  the  cartilag- 
inous formation  of  bone,  interferes  with  the  union  of  epiphysis  and 
diaphysis,  and  checks  the  growth  of  the  bone  in  length.  The  irregular 
cooperation  of  the  chondral  and  periosteal  tissues  in  the  development 
and  growth  of  the  bones  similarly  explains  the  actual  deformities  in 
their  shape.  Most  of  the  cases  belong  to  the  type  known  as  hypoplastic. 
The  epiphyses  are  normal  in  size,  and  there  is  impaired  growth  of  the 
cartilage-cells.  In  the  hyperplastic  form,  however,  which  is  rare,  the 
growth  of  cartilage  exceeds  the  normal,  and  the  epiphyses  are  enlarged. 
In  chondrodystrophia  foetalis  malacia  the  epiphyses  are  soft,  due  to 
decrease  in  the  consistence  of  the  intercellular  matrix. 

Symptoms. — The  dwarf  presents  a  peculiar  appearance;  to  such  a 
degree  is  this  true  that  he  is  often  a  source  of  revenue.  These  indi- 
viduals have  normal  intelligence,  and  being  quick  to  turn  their  physical 
defects  into  pecuniary  gain,  they  may  often  be  seen  on  the  vaudeville 


726 


THE    PRACTICE    OF    PEDIATRICS 


or  comic  opera  stage  doing  minor  roles  as  foils  to  men  of  large  stature. 
The  trunk  is  of  normal  size,  while  the  extremities  are  very  short. 
The  head  may  be  involved.  It  may  be  very  large,  showing  a  dome- 
shaped  contour,  not  unlike  that  of  hydrocephalus.  The  features  may 
be  large,  with  broad  nose  and  prominent  cheek-bones.  The  forehead 
is  usually  wide,  with  the  eyes  set  widely  apart,  due  to  the  broad  root 
of  the  nose.  The,  facial  appearance,  as  described,  while  usually  pres- 
.  ent,  is  not  necessarily  a  part  of  the  pic- 

ture. I  have  seen  several  cases  in  which 
the  facial  configuration  differed  in  no 
wise  from  that  of  the  general  average 
of  humanity,  as  shown  by  Fig.  105. 
The  muscles  of  the  extremities,  while 
short,  are  very  large  and  strong,  and 
these  little  people  oftentimes  possess 
prodigious  strength  in  lifting  or  carry- 
ing heavy  objects. 

The  appearance  of  the  child  is 
characteristic,  further,  in  that  the  hips 
are  very  heavy  and  broad,  this  ap- 
pearance being  produced  in  part  by 
the  peculiar  articulation  of  the  thigh 
with  the  trunk.  The  articulation  takes 
place  at  almost  a  right  angle,  due  to  the 
change  in  the  contour  of  the  neck  of 
the  femur.  There  is  marked  lordosis, 
the  lumbar  curve  being  markedly  ex- 
aggerated. (See  Fig.  105.)  This  causes 
a  tilting  and  narrowing  of  the  antero- 
posterior diameter  of  the  pelvis,  which 
in  girls  may  be  a  factor  influencing 
normal  childbirth  in  later  life. 

The  hands  are  usually  square,  and 
the  fingers  very  short.  The  feet  take 
on  the  same  appearance  being  short 
and  thick. 
Diagnosis. — Chondrodystrophia  may  be  confused  with  rachitis  or 
cretinism  early  in  the  first  few  months  of  life.  Rachitis  and  chondro- 
dystrophia have  been  confused,  usually  for  the  reason  that  chondro- 
dystrophia is  such  a  rare  condition  that  it  was  not  known  to  exist  and 
consequently  was  not  suspected. 

The  very  short,  thick  extremities,  together  with  the  facial  charac- 
teristics and  normal  mentality,  are  sufficient  for  a  differentiation. 
Further,  the  changes  due  to  rachitis  are  of  gradual  development,  and 
are  never  present  at  birth.  In  chondrodystrophia  the  child,  when 
very  young,  shows  an  appearance  as  characteristic  as  when  he  is  two 
years  of  age  or  older. 

Cretins  are  very  degenerate  mentally.     They  are  slow  and  stupid, 


Fig.  105. — Chondrodystrophia. 
Lateral  view. 


CRETINISM 


727 


exhibit  no  mental  response,  and  show  but  Httle  irritation  upon  manipu- 
lation. In  chondrodystrophia  the  mental  condition  is  usually  nor- 
mal; at  least  those  with  chondrodystrophia  cannot  be  placed  in  the 
class  with  the  mentally  defective. 

Prognosis. — ^I  disagree  with  those  who  claim  a  high  infant  mortality 
in  chondrodystrophia.  I  fail,  however,  to  see  that  mortahty  statistics, 
in  view  of  the  very  few  cases  that  exist,  can  be  of  value. 

Physical  Health. — I  have  had  but  five  under  my  professional  direc- 
tion as  infants,  and  all 
are  well  and  thriving  in 
their  own  way.  One,  now 
about  six  years  old,  is  the 
offspring  of  a  mother  who 
is  a  chondrodystrophiac. 
Both  men  and  women 
dwarfs  are  fertile.  Giving 
birth  to  children  is  often 
a  dangerous  procedure, 
because  of  the  antero- 
posterior narrowing  at  the 
pelvic  brim  and  a  tilting 
of  the  pelvis. 

Treatment. — Treat- 
ment  is  of  no  avail,  no 
means  having  been  dis- 
covered to  induce  growth. 

CRETINISM      (INFANTILE 

MYXEDEMA;  CRETINOID 

IDIOCY) 

Cretinism  was  de- 
scribed  by  Paracelsus 
early  in  the  seventeenth 
century.  Until  the  mid- 
dle of  the  nineteenth  cen- 
tury, however,  the  disease 
was  only  imperfectly 
differentiated.  Fagge  de- 
scribed the  sporadic  form 
in  1871,  and  in  1873  Gull  emphasized  the  similarity  of  this  disease  to 
adult  myxedema.  Some  years  later,  following  the  experiments  con- 
ducted by  Victor  Horsley,  a  commission  appointed  by  the  Clinical 
Society  of  London  reported  that  myxedema  and  cachexia  strumi- 
priva  were  identical,  that  sporadic  cretinism  was  myxedema  occur- 
ring in  childhood,  and  that  endemic  cretinism  was  closely  allied 
to  myxedema.  The  successful  work  of  Schiff,  von  Eiselsberg,  and 
Horsley  in  the  artificial  grafting  of  thyroid  gland  induced  George  R. 
Murray  in  1891,  to  employ  hypodermic  injections  of  an  extract  of  the 


Chondrodystrophia . 


728 


THE    PRACTICE    OF    PEDIATRICS 


gland  in  the  treatment  of  myxedema.  Howitz,  Fox,  and  MacKenzie 
obtained  equally  good  results  from  thyroid  medication  by  mouth. 
The  wonderful  success  of  this  form  of  organotherapy  during  the  five 
years  following  its  initial  use  led  Osier  to  write:  "Not  the  magic  wand 
of  Prospero,  or  the  brave  kiss  of  the  daughter  of  Hippocrates,  ever 
effected  such  a  change." 

Cretins  usually  do  not  come  under  observation  before  the  sixth 
month.  Not  much  is  expected  of  a  baby  of  a  few  months  old,  and  if  he 
is  very  quiet  and  slow  at  noticing  his  surroundings,  the  fact  is  attri- 
buted to  his  tender  age  or  to  his  being  a  good  baby.     When,  however, 

at  the  fifth,  sixth,  or  seventh  month,  he 
fails  to  show  the  usual  response  for  his 
age,  medical  attention  is  called  to  the 
condition.  My  youngest  patient  was 
three  months  old.  When  first  seen,  the 
patients  have  usually  been  from  six  to 
eighteen  months  old.  My  oldest  case 
was  four  years  of  age.  A  cretin  girl 
was  three  years  old  (Fig.  108)  and 
weighed  15  pounds,  3  ounces. 

Etiology. — It  is  undoubtedly  estab- 
lished that  the  "condition"  termed 
cretinism  depends  upon  the  absence  of 
the  thyroid  secretion,  and  that  the 
various  degrees  of  cretinoid  idiocy  hinge 
upon  the  partial  or  complete  absence  of 
the  thyroid  gland.  Cretinism  varies  in 
degree  and  in  the  time  of  its  develop- 
ment. In  typical  cases  (Fig.  107)  there 
is  complete  absence  of  the  thyroid  gland; 
in  others,  showing  the  disease  in  less 
severe  form,  an  impaired  thyroid  is 
found. 

Pathology. — In  16  autopsies  collected 
by  Fletcher  Beach  the  thyroid  was  absent 
in  14.  In  100  cases  of  Curling,  Fagge, 
and  Iphophon  the  gland  was  found 
absent  in  25;  in  the  other  75,  various  connective-tissue  and  colloidal 
changes  were  observed.  In  endemic  cretinism  ("not  found  in  this 
country,"  Osier)  alterations  are  found  in  the  thyroid  consisting  of 
partial  or  complete  degeneration,  which  may  be  either  atrophic  or 
goitrous  in  its  inception;  or,  as  Getzowa  has  described,  cases  are 
found  in  which  atrophic  areas  and  goitrous  degenerated  nodules  al- 
ternate in  the  same  gland.  In  sporadic  cretinism  there  is  usually  con- 
genital absence,  while  in  infantile  myxedema  due  to  acquired  loss  or 
perversion  of  thyroid  function  in  the  early  years  of  life  the  symptoms 
vary  according  to  the  amount  of  functional  disturbance  of  the  gland. 
According  to  Kocher,  in  myxedema  there  is  always  abolition  of  the 


Fig.  107. — Cretin  four  j^ears 
old.  Never  received  thyroid 
treatment. 


CRETINISM 


729 


Fig.  108. — Cretin  three  years  old. 
treatment. 


Before 


function  of  the  gland,  which  at  autopsy  is  never  normal.  In  the  ma- 
jority of  cases  it  is  re- 
placed by  a  band  of  tis- 
sue (Virchow) ;  at  other 
times,  by  adipose  tissue 
without  a  trace  of  the 
thyroid  artery  (Stilling). 
Ord  was  the  first 
man  to  examine  micro- 
scopically the  thyroid  in 
a  case  of  myxedema.  In 
the  majority  of  instances 
neither  Virchow  nor 
Horsley,  in  their  exten- 
sive observations,  was 
able  to  find  vestiges  of 
acini  or  thyroid  cells — 
bunches  of  connective 
tissue  occupying  the  re- 
gion of  the  gland.  Still- 
ing made  similar  inves- 
tigations, and  found  the 
thyroid  artery  missing,  while  Langhans  states  the  changes  to  be 
those  of  an  interstitial  inflammation,  with  embryonal  cell  infiltration ; 

in    fact,    an   inflammation 
comparable  to  cirrhosis  of 
^^^^^  ^^K^ggB  ^]^Q  liver.      By  degrees  the 

^^^^^  ^IHJilV  tissues     become     sclerosed 

I  ^^^^^  ^^^    ^^6    vessels    undergo 

i  NBfefc  ....       -*'  ><ttaiiiii  ,-■■  endarteritis    obliterans, 

while  the  acini  become 
atrophied  and  disappear. 
As  these  changes  progress 
the  function  of  the  gland 
diminishes. 

The  parathyroids  are 
normal.  The  hypophysis 
cerebri  is  atrophied  in  some 
cases  and  hypertrophied  in 
others.  The  brain  shows 
no  gross  abnormality.  The 
genitals  are  infantile  in 
character.  The  skin  is 
thick,  with  a  scanty  de- 
velopment of  hair  and 
sweat-glands.  The  adipose  tissue  is  very  abundant,  both  beneath  the 
skin  and  in  the  omentum;  often  there  are  pads  of  fat  above  the  clav- 


Fig.  109. 


Cretin  after  thirty-four  days' 
thyroid  treatment. 


730  THE    PRACTICE    OF    PEDIATRICS 

icles.  The  entire  osseous  system  shows  a  lack  of  development  and 
ossification. 

Symptoms. — When  very  young — under  one  year  of  age — the  chil- 
dren are  dull  and  mentally  inactive;  they  are  passive,  and  show  little 
or  no  interest  in  their  surroundings ;  they  resist  manipulations,  such  as 
dressing,  bathing,  and  physical  examination,  but  little,  if  at  all.  The 
extremities  usually  are  cool,  oftentimes  slightly  moist. 

The  general  appearance  is  characteristic  (see  Fig.  107),  regardless 
of  the  child's  age.  The  hair  is  dry  and  coarse;  the  face  is  broad;  the 
nose  wide  and  flat,  and  the  lips  are  broad  and  thick.  The  tongue  pro- 
trudes between  the  lips.  The  tissues  have  a  doughy,  edematous 
appearance  and  feel  boggy  to  the  touch,  but  do  not  pit.  The  forehead 
is  low.  The  abdomen  is  usually  large,  and  there  is  almost  invariably 
an  umbilical  hernia.  The  neck  is  short  and  thick.  The  hands  and 
feet  are  large;  the  fingers  and  toes  are  short  and  thick.  The  patients 
are  very  short  in  stature.  (The  child  shown  in  Fig.  108  was  but  26 
inches  tall  when  three  years  of  age.)  The  fontanel  is  widely  open. 
Dentition  is  greatly  delayed.     The  temperature  is  usually  subnormal. 

The  cretin  walks  late,  rarely,  if  untreated,  before  the  third  year. 
Fig.  107  represents  a  cretin  four  years  old  who  cannot  stand  without 
assistance.  He  is  313>^^  inches  tall.  Mentally  and  physically  such 
individuals  are  slow  and  inactive.  The  mental  impairment  is  consid- 
erable, idiocy  being  the  outcome  in  most  of  the  untreated  cases. 

Acquired  Cretinism. — In  some,  early  development  is  fairly  normal- 
and  the  unmistakable  signs  do  not  appear  until  the  child  is  several 
months  of  age. 

Illustrative  Case. — A  girl,  three  and  one-half  years  of  age,  with  delayed  or 
acquired  cretinism,  was  brought  to  me  from  another  city.  The  child  was  perfectly 
normaluntil  the  third  year  of  age.  She  then  became  inactive  and  took  no  interest 
in  her  surroundings.  The  hair  became  coarse  and  dry,  the  extremities  cool.  The 
expression  was  dull  and  listless.  The  child  presented  a  general  edematous  ap- 
pearance. The  diagnosis  of  cretinism  was  proved  by  a  prompt  response  to  thyroid 
medication. 

Diagnosis. — The  diagnosis  in  typical  cases  is  without  difficulty. 
The  nature  of  the  trouble  is  stamped  on  every  feature.  The  slow 
mental  responses  and  the  dwarfed,  edematous  extremities  furnish  a 
picture  that  is  simulated  by  but  one  other  condition,  and  this  is 
Mongolian  idiocy.  In  the  Mongolian  the  round  face,  the  elliptic  eye, 
and  the  absence  of  shortening  in  the  long  bones  are  sufficient  to  estab- 
lish a  differentiation. 

Prognosis. — The  prognosis  for  a  complete  recovery  is  good  if  the 
case  is  discovered  before  the  eighth  month.  I  have  several  patients 
under  treatment  who  are  apparently  normal  children  when  judged  by 
school  and  family  standards.  No  one  knows  that  these  children  are 
cretins.  In  those  in  whom  treatment  is  not  begun  until  after  the  first 
year — surely  after  the  eighteenth  month — the  chances  of  normal  men- 
tality are  lessened.  The  earlier  the  case  comes  under  treatment,  the 
better  the  possibilities  for  the  patient,  both  physically  and  mentally. 


CRETINISM  731 

Treatment. — The  Thyroid  Treatment. — The  specific  treatment  is 
the  thyroid  treatment.  The  most  pronouncedly  beneficial  results  of 
this  treatment  are  noticed  when  it  is  brought  into  use  early  in  life. 
The  diagnosis  of  cretinism  is  rarely  made  before  the  fifth  or  sixth 
month,  often  much  later,  for  the  reason  that  the  case  does  not  hap- 
pen to  come  under  the  observation  of  those  competent  to  make  the 
diagnosis. 

Illustrative  Cases. — In  two  cases  the  patients  were  first  seen  by  me  at  the  fifth 
and  the  seventh  month  respectively.  Other  cases  have  been  treated  in  institution 
and  in  private  work.  The  two  referred  to,  however,  were  seen  earlier  and  almost 
daily  for  months,  consequently  there  was  an  excellent  opportunity  for  observing 
the  effects  of  the  thyroid  administration.  The  desiccated  thyroid  extract  of 
Parke,  Davis  &  Co.  was  used. 

A  fairly  complete  history  of  the  progress  of  one  of  the  cases  is  as  follows :  The 
beneficial  effects  were  noticed  in  three  days.  The  first  change  for  the  better  was 
observed  by  the  mother,  who  stated  that  the  child  seemed  warmer  and  that  less 
bed-clothing  was  necessary.  The  next  positive  change  occurred,  according  to  my 
records,  on  the  fifth  day  of  treatment.  The  child's  general  condition  was  very 
much  improved.     Her  extremities  were  warmer,  her  color  better,  and  she  com- 


Fig.  110. — Cretin,  aged  six  months,  before  beginning  thyroid  treatment. 

menced  to  use  her  arms;  but  what  particularly  impressed  the  mother  was  that 
less  bed-clothing  was  needed  to  keep  the  child  warm.  At  about  the  seventh  day  of 
treatment  the  patient  cried  vigorously  when  disturbed  for  the  purpose  of  changing 
the  napkin — something  which  she  had  never  done  before.  She  had  previously 
been  stupid  and  apathetic.  The  next  changes  for  the  better  rapidly  followed;  the 
patient  noticed  and  appeared  interested  in  her  mother,  and  followed  the  latter 
about  the  room  with  her  eyes,  and  while  previously  the  child  had  rarely  used  her 
legs  and  arms  except  when  disturbed,  she  now  began  to  move  them  about  volun- 
tarily; as  the  mother  expressed  it,  "The  child  had  acted  as  though  she  were  under 
the  influence  of  some  powerful  depressing  drug  whose  effects  were  gradually 
wearing  off."  When  the  child  was  five  and  one-half  months  old,  after  she  had  been 
under  treatment  for  sixteen  days,  receiving  }i  grain  of  thyroid  twice  daily,  she 
smiled  for  the  first  time.  She  cut  the  first  tooth  at  the  ninth  month,  and  walked 
alone  at  the  fourteenth  month.  She  is  now  taking  5  grains  daily,  and  is  apparently 
normal  in  every  respect.  She  attends  school,  and  is  but  one  grade  below  the 
average  school-child  of  her  age,  which  means  that  she  is  in  the  same  grade  with 
other  children  who  are  normal. 

When  the  child  in  whom  treatment  was  commenced  at  the  seventh  month  was 
nine  months  of  age,  it  was  found  necessary  to  give  J^  grain  three  times  daily.  One 
month  later  ^i  grain  was  given  four  times  daily.     At  this  time  the  child  could  sit  up 


732  THE    PRACTICE    OF    PEDIATRICS 

and  hold  the  head  erect.  The  mcrease  in  the  thyroid  extract  produced  vomiting, 
and  the  dosage  of  J^  grain  three  times  daily  was  resumed.  One  year  after  the  com- 
mencement, of  the  treatment,  when  the  patient  was  nineteen  months  old,  2  grains 
daily  were  required. 

In  both  of  these  infants  the  protrusion  of  the  tongue  was  one  of  the  latest 
symptoms  to  disappear. 

Dosage. — The  mcrease  in  the  thyroid  administration  must  be  deter- 
mined by  the  condition  of  the  patient.  As  long  as  progress  is  shown  in 
more  active  and  normal  mentality,  with  an  increase  in  the  growth  of  the 
long  bones  and  a  gradual  loss  of  the  typical  facial  and  bodily  character- 
istics, it  is  unwise  to  increase  the  dosage  of  the  thyroid.  When,  how- 
ever, a  period  arrives  when  no  progress  appears  to  be  made,  the  daily 
dosage  should  gradually  be  increased  by  }i  grain.  Evidences  of 
overdosage  are  pallor,  prostration,  perspiration,  and  indigestion.  When 
any  of  the  above  signs  present  themselves,  the  niedication  should  be 
discontinued  for  twenty-four  hours  and  then  resumed  with  smaller 
doses. 

My  cases  have  varied  considerably  as  to  the  amount  of  thyroid 
required.  The  dosage  used  was  that  taken  by  those  in  whom  the  dis- 
ease was  discovered  very  early  in  life.  The  older  the  patient  when  the 
thyroid  medication  is  begun,  the  less  marked  are  the  beneficial  results. 

Illustrative  Cases. — I  have  a  girl  five  years  of  age  under  treatment  at  the 
present  time  who  came  under  my  care  two  years  ago  weighing  15  pounds  and  3 
ounces.  She  made  a  marvelous  improvement  under  J'^  grain  of  thyroid  twice  a 
day,  which  in  two  weeks  was  increased  to  }i  grain  three  times  a  day.  _  This  we 
were  obliged  to  decrease  because  of  the  prostration  and  perspiration  which  it  ap- 
peared to  occasion.  The  dosage  of  %  grain  three  times  daily  could  not  be  used 
until  she  was  four  years  of  age.  She  is  now  five  years  old  and  requires  1  grain 
three  times  a  day.  In  this  child  the  most  remarkable  improvement  was  noted. 
(See  Figs.  108  and  109.) 

The  interval  of  time  between  the  photographs  was  thirty-four  days.  Six  teeth 
were  cut  in  three  weeks  after  beginning  the  treatment,  and  14  more  were  cut  during 
the  next  six  months.  The  child  made  corresponding  improvement  in  every  other 
respect.  _  ' 

Another  girl  patient,  now  nine  years  old,  and  normal  in  every  respect  except 
that  her  hair  is  rather  coarse,  with  a  tendency  to  dryness  of  the  scalp,  was  found  to 
require  the  following  amounts  of  desiccated  thyroid  at  the  various  ages: 

Six  months 1 J^  grains  daily 

One  year 3>^     " 

Two  years 5         "  " 

Three  years 9         "  " 

Four  years 8         "  " 

This  patient  both  walked  and  talked  at  fifteen  months.  In  her  case,  in  order 
to  determine  what  the  effects  of  the  withdrawal  of  the  treatment  might  be,  the 
thyroid  was  discontinued.  This  was  first  attempted  when  she  was  two  and  one- 
half  years  of  age.  The  mother  was  asked  to  keep  close  watch  in  order  to  detect 
the  slightest  difference  in  the  child's  behavior.  After  three  days  without  thyroid 
it  was  noticed  that  the  child  became  less  active  and  disinclined  to  play.  She  was 
not  irritable  or  cross,  but  would  sit  in  her  little  chair  the  entire  day.  She  had 
previously  been  very  bright,  active,  and  talkative.  A  few  days  later  she  ceased  to 
talk  voluntarily  and  answered  only  when  spoken  to.  After  an  interval  of  twelve 
days  the  thyroid  was  resumed,  and  her  activity  again  returned.  About  one  year 
later  a  similar  trial  was  attempted  with  similar  results,  although  the  duration  of  the 
test  was  shorter,  as  the  mother,  who  was  a  dispensary  patient  and  had  had  the 
thyroid  furnished  her,  purchased  a  bottle  of  tablets  and  gave  them  on  her  own 
responsibility.  The  child,  when  nine  years  old,  was  taking  12  grains  daily.  She 
was  a  normal,  healthy  school-girl,  alive  to  all  interests  of  girlhood,  and  no  one  out- 
side the  family  circle  in  the  village  where  she  resided  knew  that  she  was  a  cretin. 


DWARFS  733 

The  thyroid  mu.st  be  continued  during  the  Hfe-time  of  the  patient ; 
when  it  is  discontinued,  the  mental  processes  soon  begin  to  lag.  In- 
difference to  surroundings  and  aversion  to  physical  effort  soon  appear, 
all  to  disappear  again  when  the  thyroid  is  resumed. 

DWARFS 

In  dwarfism  there  is  an  underdevelopment  of  all  parts  of  the  body 
both  of  the  skeleton  and  of  the  soft  parts.  It  cannot  be  doubted  that 
this  condition  is  purely  dependent  upon  a  congenital  tendency,  but  the 
same  effects  can  be  produced,  at  least  in  so  far  as  the  inhibition  of  growth 
is  concerned,  by  harmful  influences  exerted  during  the  period  of  devel- 
opment and  growth.  Thus  one  cannot  always  tell  with  certainty 
whether  an  abnormal  bodily  growth  is  dependent  upon  a  congenital 
tendency  or  upon  pathologic  influences  during  the  period  of  growth. 

A  true  dwarf  is  a  person  of  small  stature,  not  deformed,  whose  de- 
velopment has  proceeded  symmetrically  and  at  a  normal  rate  (except 
as  regards  extent)  in  comparison  with  other  races,  families  of  the  same 
race,  or  members  of  the  same  family.  According  to  Sainton,  a  dwarf 
should  not  exceed  59  inches  (1.5  meters).  His  best  illustration  is  the 
race  of  pigmies  in  Central  Africa,  whose  height  is  about  four  feet.  In 
them  the  dwarfing  is  not  due  to  any  pathologic  process.  Sexual  devel- 
opment, epiphyseal  union,  and  ossification  take  place  at  the  usual 
time. 

Symptomatic  infantilism  or  dwarfism  is  a  term  used  for  dwarfism 
associated  with  delayed  ossification,  dentition,  and  sexual  development. 
It  is  usually  the  result  of  some  illness  or  disturbance  of  nutrition  which 
interferes  with  growth.  In  these  cases  the  body  is  undeveloped,  weak, 
and  slender.  Usually  there  is  both  mental  and  physical  delay.  The 
common  causes  are  general  dystrophies,  congenital  heart  disease, 
tuberculosis,  and  syphilis.  This  condition  may  also  be  due  to  a  defi- 
ciency of  the  internal  secretions,  rickets,  spinal  caries,  and  lateral 
curvature.  Another  type  which  is  described  by  Loraine  is  due  to  a 
congenital  nondevelopment  of  the  arteries  (an  angioplasia) . 

According  to  Hastings  Gilford,  true  dwarfism  (ateliosis)  is  divided 
into  two  groups — asexual  and  sexual.  The  subjects  are  well  propor- 
tioned, with  childish  faces  and  intelligence,  irregular  and  backward 
teeth,  small  bones  and  muscles,  and  an  imperfect  sexual  system.  In  the 
first  type  the  whole  body  is  affected,  but  the  sexual  organs  are  the  most 
backward.  The  arrest  in  development  may  occur  at  any  time  of  life, 
and  hence  the  subjects  are  not  dwarfs.  There  is  usually  but  one  in  a 
family.  The  body  proportions,  contour,  and  intelligence  are  those  of  a 
child,  and  the  testes  are  commonly  undescended.  In  sexual  ateliosis 
the  development  is  always  delayed  until  puberty.  The  epiphyses  then 
unite,  and  the  sexual  organs  mature  normally.  The  child  resembles  a 
miniature  adult,  but  retains  the  physiognomy,  proportions,  and  stature 
of  a  child.  These  patients  differ  from  physiologic  dwarfs  (pigmies) 
in  the  retention  of  many  childish  characteristics.     Sexual  ateliosis  is 


734  THE    PRACTICE    OF    PEDIATRICS 

frequently  hereditary,  and  some  of  the  affected  individuals  may  have 
children  with  dwarfism  of  the  asexual  type,  thus  suggesting  a  relation- 
ship between  the  two. 

Cretinism  and  chondrodystrophy  are  treated  under  separate  head- 
ings. The  cases  are  often  classed  with  those  of  dwarfs,  but  do  not  rep- 
resent true  dwarfism,  as  the  subjects  are  dwarfed  in  stature  only,  and 
in  the  cretin  growth  takes  place  under  thyroid  therapy  if  the  case  is  seen 
early  in  life. 

DIABETES  INSIPIDUS 

Persistent  polyuria — diabetes  insipidus — is  rare  in  children.  The 
disease  is  characterized  by  extreme  thirst  and  the  passage  of  large 
quantities  of  pale  urine,  the  condition  continuing  for  months  and  years. 

Temporary  or  transient  polyuria  is  of  occasional  occurrence.  There 
is  unusual  thirst  and  the  passageof  abnormally  large  amounts  of  urine,, 
a  condition  continuing  for  a  few  days  or  a  week  or  two. 

Etiology. — The  cause  of  persistent  polyuria  is  but  little  understood. 
Cases  are  on  record  in  which  the  condition  has  seemed  to  be  closely 
associated  with  brain  tumors,  hydrocephalus,  and  trauma.  But  three 
cases  have  come  under  my  observation.  In  these  three  no  cause  could 
be  discovered.  Temporary  or  transient  polyuria,  under  my  observe- 
tion,  has  always  existed  in  nervous  girls  of  hysteric  tendencies.  It  is 
most  apt  to  develop  near  the  close  of  the  school  year,  when  the  child 
is  considerably  reduced  or  somewhat  excited  in  anticipation  of  under- 
going examinations. 

Diagnosis. — Polyuria  is  to  be  differentiated  from  diabetes  mellitus 
by  examination  of  the  urine.  The  absence  of  sugar  determines  the 
diagnosis. 

Symptoms. — In  both  the  mild  and  severe  cases  there  are  thirst  and 
the  passage  of  large  amounts  of  urine,  the  amount  of  urine  ranging  from 
50  to  100  ounces  daily.  The  specific  gravity  is  low — 1002  to  1010. 
The  amount  of  urea  and  uric  acid  excreted  varies  but  little  from  the 
normal. 

In  two  of  the  cases  of  true  diabetes  insipidus  there  were  a  secondary 
anemia  and  a  moderate  degree  of  malnutrition.  One  patient  was  much 
undersized,  and  at  the  age  of  five  and  one-half  years  weighed  30)-^ 
pounds  and  was  373^^  inches  high.  That  the  lack  of  development  was 
due  to  the  polyuria,  however,  is  extremely  doubtful. 

Treatment. — In  the  cases  of  functional  nervous  origin  the  cure  takes 
placebyachangeof  environment .  When  the  nervous  stress  is  removed , 
the  symptoms  subside. 

In  the  true  cases  no  means  of  treatment  have  been  of  avail  in  my 
hands.  In  the  case  of  the  boy  referred  to,  various  methods  of  manage- 
ment have  been  attempted  without  success.  With  a  diminution  of  the 
fluids  taken  there  is  a  corresponding  reduction  in  the  output.  As  soon 
as  he  is  allowed  freedom  in  drinking,  the  frequency  in  urination  and 
the  polyuria  return.     Drugs  have  been  of  no  value. 


DIABETES    MELLITUS  735 


DIABETES  MELLITUS 


True  diabetes  in  children  is,  fortunately,  a  comparatively  rare 
disease. 

Etiology. — The  cause  of  diabetes  mellitus  is  not  known.  Heredity 
is  supposed  to  play  an  important  part.  In  11  cases  in  children  under 
nine  years  of  age  no  etiologic  factor  could  be  discovered.  My  youngest 
case  seen  was  nine  months  of  age  at  death.  The  disease  was  known  to 
have  existed  but  three  weeks.  Various  theories  have  been  advanced 
from  time  to  time,  but  we  are  still  as  much  in  the  dark  as  were  our  med- 
ical forefathers.  Heredity  is  supposed  to  be  a  factor.  In  not  one  of 
my  cases  was  there  a  diabetic  association  of  this  form.  Among  adults, 
Hebrews  are  more  liable  to  the  disease  than  others.  Jewish  children 
have  shown  no  special  tendency  thereto. 

Pathogenesis  and  Morbid  Anatomy. — In  "A  Study  of  the  Patho- 
logical Anatomy  of  the  Pancreas  in  90  Cases  of  Diabetes  Mellitus" 
published  in  1909,  R.  L.  Cecil  reviews  the  work  of  Opie,  von  Mering, 
Minkowski,  Sauerbeck,  and  others,  and  reports  that  anatomic  lesions 
of  the  pancreas  occur  in  more  than  seven-eighths  of  all  cases.  In  the 
cases  associated  with  lesions  of  this  organ  the  islands  of  Langerhans 
were  constantly  involved  in  changes  ranging  from  sclerosis  and  hyaline 
degeneration  to  infiltration  with  leukocytes  and  hypertrophy,  while 
in  some  cases  these  islands  were  the  only  portions  of  the  gland  involved. 
In  12  per  cent,  of  the  cases  investigated  no  pathologic  changes  were 
found,  although  in  half  of  the  12  per  cent,  the  gland  was  smaller,  or  the 
number  of  islands  less  than  normal.  Three-fourths  of  the  cases  pre- 
senting no  lesions  occurred  in  patients  under  the  age  of  thirty. 

Abt  and  Strouse  have  reported  two  cases  of  traumatic  diabetes 
in  children.  In  one  the  diabetic  symptoms  followed  a  fall  on  the 
head.  In  the  other  the  injuries  were  associated  with  only  a  brief 
period  of  unconsciousness,  and  the  chief  lesion  was  a  compound  frac- 
ture of  the  tibia.  Both  patients  developed  persistent  glycosuria  and 
other  diabetic  symptoms,  and  responded  typically  to  treatment. 
Other  cases  might  be  cited  of  injuries  varying  from  simple  concussion 
to  fracture  of  the  skull,  with  a  subsequent  glycosuria  or  even  permanent 
diabetes.  Langstein  records  a  persistent  glycosuria  in  two  young 
infants  affected  respectively  by  hydrocephalus  and  malformation  of 
the  brain. 

Very  recently  the  subject  of  experimental  diabetes  has  been  inves- 
tigated by  MacLeod.  He  states  that  dextrose  may  appear  in  the  urine 
as  a  result  of  deficient  utilization  of  this  carbohydrate  by  the  tissues, 
because  of  deficient  renal  function  permitting  the  escape  of  sugar  nor- 
mally present  in  the  blood,*  or  because  of  an  increased  production  of 
dextrose  in  the  liver.  To  the  last  of  these  sources  of  a  hyperglycemia 
he  attaches  the  greatest  importance.  The  hepatic  conversion  of  the 
glycogen  into  dextrose  is  shown  to  be  influenced  by  a  reflex  mechanism 

*  Under  normal  conditions  the  blood  contains  about  0.1  to  0.15  per  cent,  of 
glucose. 


736  THE    PRACTICE    OF    PEDIATRICS 

operating  through  the  fourth  ventricle  and  the  splanchnic  nerves. 
That  certain  drugs  and  the  carbon  dioxid  present  in  the  blood  in 
asphyxia  may  produce  hyperglycemia  by  their  effects  on  these  nerve- 
centers  controlling  glycogen  conversion  is  considered  probable.  The 
influence  of  secretions  from  such  sources  as  the  pancreas,  thyroid,  and 
adrenals,  while  probably  important,  is  not  yet  fully  understood. 

The  Urine. — The  urine  is  ordinarily  increased  in  amount,  clear, 
acid,  and  of  high  specific  gravity — 1025  to  1050.  The  amount  of 
glucose  present  varies  widely,  depending  on  the  character  of  the  diet, 
time  of  day,  and  time  of  meals.  During  certain  periods  the  sugar 
may  be  absent.  Acetone,  diacetic  acid,  and  beta-oxybutyric  acid 
may  be  found,  depending  on  the  severity  of  the  disease.  The  first 
two  of  these  substances  are  oxidation  products  of  the  third,  which 
appears  only  in  severe  cases. 

Symptoms.— Diabetes  mellitus  is  very  constant  in  its  symptoma- 
tology in  children.  An  early  and  never-failing  sign  is  loss  of  weight 
without  apparent  cause.  The  loss  of  weight  is  so  pronounced  that  it  is 
often  the  first  symptom  to  which  the  attention  is  called.  Thirst  is  also 
an  early  symptom.  It  is  of  a  very  urgent  nature.  The  child  never 
seems  to  be  satisfied.  The  thirst  is  so  great  that  the  patient  is  awak- 
ened by  it  in  the  night  and  demands  water.  Milk  or  any  fluids  will  be 
taken,  but  if  a  choice  is  given,  water  will  be  selected.  Repeatedly 
I  have  known  patients,  if  allowed,  to  drink  5  or  6  quarts  of  water  a 
day. 

Frequent  urination  is  always  present,  large  amounts  being  voided; 
100  ounces  in  twenty-four  hours  is  not  uncommonly  excreted  by  quite 
young  children.  Enuresis  occurs  in  over  half  the  cases.  The  skin  is 
dry;  perspiration  rarely  occurs  even  on  the  hottest  days  or  when  the 
body  is  covered  with  warm  clothing.  A  light  brawny  desquamation 
is  not  infrequently  seen. 

The  child  becomes  listless.  There  is  disinclination  to  play,  and  the 
interest  in  childish  things  flags. 

The  appetite  is  usually  voracious,  the  child  not  at  all  particular  as 
to  the  kind  of  food  taken.  No  matter  how  carefully  the  food  is  selected 
and  prepared,  the  emaciation  continues. 

As  the  case  makes  its  inevitable  progress  toward  dissolution  the 
emaciation  progresses  and  the  weakness  increases  until  the  patient  is 
confined  to  bed.  If  an  intercurrent  disease,  such  as  bronchopneu- 
monia, does  not  terminate  the  illness,  the  child  dies  from  exhaustion 
or  acetonemia. 

Diagnosis. — The  presence  of  diabetes  is  suggested  by  loss  in  weight 
and  strength,  in  association  with  a  voracious  appetite  and  inordinate 
thirst  and  dryness  of  the  skin.  An  examination  of  the  urine  determines 
the  diagnosis.  The  disease  may  be  confused  with  persistent  polyuria 
and  with  chronic  interstitial  nephritis.  Here  again  the  differentiation 
is  made  by  the  urine  examination. 

Duration  of  the  Disease. — Few  cases  live  longer  than  a  year.  The 
majority  of  the  cases  terminate  fatally  in  from  three  to  six  months. 


ACETONURIA  737 

Prognosis. — All  my  cases  died  within  less  than  a  year  after  the 
diagnosis  was  made.     True  diabetes  is  a  fatal  disease  in  children. 

Treatment. — My  10  patients  have  been  treated  by  limiting  the 
amount  of  fluid  taken,  by  restricting  the  diet,  and  by  using  the  opium 
derivatives  and  arsenic  to  the  point  of  physiologic  effect,  all  without 
the  slightest  benefit.  Bicarbonate  of  soda,  furthermore,  has  been  given 
in  large  dosage.  The  sugar  output  was  reduced,  but  the  patients 
showed  not  even  temporary  improvement  in  general  condition. 

Diet. — The  following  are  permissible  articles  of  diet  for  a  child  ill 
with  diabetes;  Soup  and  broths  made  from  meat,  fresh  and  salt  fish, 
shell-fish,  occasionally  egg,  fowl,  and  game,  smoked  meats,  sweetbread, 
cheese,  spinach,  celery,  lettuce,  cucumbers,  cranberries,  radishes, 
string-beans,  asparagus,  squash,  cabbage,  egg-plant,  tomatoes,  onions, 
turnips,  mushrooms,  gelatine  jellies  sweetened  with  saccharin,  butter, 
cream,  olive  oil,  cod-liver  oil,  lemon,  grape-fruit,  sour  apples,  black- 
berries, raspberries,  watermelon.  Nuts  of  all  kinds  may  be  eaten. 
Only  bread  and  biscuits  made  from  gluten  flour  should  be  used.  It  is 
impossible  to  procure  a  starch-free  gluten  flour;  the  flour,  however, 
should  not  contain  more  than  20  per  cent,  of  starch. 

ACETONURIA  IN  CHILDREN 

Acetone  bodies  occur  in  the  urine  in  a  wide  variety  of  disorders, 
and  are  due  to  defective  fat  metabolism.  They  are  present  in 
diabetes,  acidosis,  inanition  and  malignant  diseases.  They  may  be 
present  in  practically  every  other  disease  of  childhood,  particularly 
in  the  exanthemata. 

The  presence  of  acetone  in  the  urine  is  not  necessarily  due  to 
starvation  or  fever  as  we  find  it  repeatedly  when  these  conditions  do 
not  exist.  We  have  found  it  repeatedly  in  children  who  were  on  a 
full  carbohydrate  diet.  I  have  had  two  cases  in  which  the  patients 
showed  a  persistent  acetonuria  when  on  ordinary  foods.  The  odor 
of  the  acetone  breath  had  been  noticed  by  the  mother  in  each  case. 
When  the  fats  were  entirely  eliminated  from  the  diet,  the  acetone 
disappeared. 

Illustrative  Cases. — A  boy  six  years  of  age  had  repeated  seizures 
of  periodic  fever,  the  temperature  ranging  from  103  to  105°F.  for  four 
or  five  days,  without  other  signs  than  excessive  acetone  in  the  urine. 
There  had  been  several  of  these  attacks  during  the  previous  two  years, 
one  about  every  two  or  three  months.  Treatment  during  the  second 
year  had  not  been  attempted  because  the  child  recovered  just  as  well 
without  treatment.  "The  fever  had  to  run  its  course."  With  elimina- 
tion of  fat,  eggs  and  cane  sugar  from  the  diet,  the  attacks  ceased, 
there  having  been  no  further  attacks  in  five  years. 

Children  who  readily  develop  acetonuria  do  not  necessarily  have 
attacks  of  true  acidosis.     Children,  however,  who  are  subject  to  attacks 
of  true  acidosis,  will  frequently  have  acetone  in  the  urine  with  minor 
ailments  with  fever. 
47 


738  THE    PRACTICE    OF    PEDIATRICS 

Treatment. — Fats  must  be  given  sparingly,  cane  sugar  should 
be  given  in  small  quantities  if  at  all.  The  usual  diet  contains  sufficient 
carbohydrate  to  supply  the  needs  of  children,  without  cane  sugar. 
If  sugar  is  given  it  is  best  to  use  honey  or  maple  sugar. 

PELLAGRA 

Pellagra  is  a  systemic  disease  with  a  course  typically  marked 
by  intermissions,  affecting  chiefly  the  skin,  gastro-intestinal  tract 
and  nervous  system.  This  disease  has  undoubtedly  been  endemic 
in  Southern  Europe  for  centuries  and  has  long  been  known  under 
such  names  as  "Alpine  Scurvy,"  "Corn-bread  Disease"  and  "Italian 
Leprosy."  In  the  past  two  decades  it  has  assumed  special  prominence 
in  the  Southern  United  States.  The  first  recorded  descriptions  are 
those  of  Cazal  and  of  Frapoli,  made  about  the  middle  of  the  eight- 
eenth century.  Today  it  is  estimated  that  there  are  100,000  cases 
in  Italy  and  about  25,000  in  the  United  States. 

Etiology. — Pellagra  has  been  generally  regarded  as  a  metabolic 
disease  of  food  origin  rather  than  an  infectious  disease.  Dermatitis 
of  the  characteristic  type  has  been  produced  experimentally  by  Gold- 
berg, in  individuals  who  were  fed  on  a  diet  rich  in  maize  and  rice  to 
the  exclusion  of  animal  and  legume  proteins,  but  whether  the  con- 
dition is  due  to  deficiency  of  vitamins  in  maize,  toxins  derived  from 
maize,  poisons  germinated  in  diseased  corn  or  should  be  viewed  as 
an  example  of  anaphylaxis  affecting  particularly  tissues  sensitized 
by  exposure  to  the  sun  has  not  been  elucidated.  Probably  the 
most  convincing  view  as  to  the  origin  of  pellagra  is  that  afforded  by 
Alessandrini  and  Scala  who  state  positively  that  it  is  a  form  of  chronic 
acid  intoxication  caused  by  colloidal  silica  in  drinking  water  and 
that  the  disease  is  localized  and  contracted  only  in  those  regions  where 
the  water  supply  is  derived  from  clay  soils.  The  explanation  of  the 
production  of  the  disease  is  thus  purely  biochemical.  The  silica  in 
colloidal  solution  attaches  to  proteid  substances,  and  in  this  manner 
it  fixes  salts  in  the  tissue  cells  of  the  body  with  the  liberation  of  water 
and  an  acid — most  frequently  hydrochloric  acid.  The  abstraction 
of  the  water  and  the  diminution  in  alkalinity  of  the  tissue  fluids  thus 
induced  are  productive  of  the  drying  of  the  tissues  and  the  acid  in- 
toxication which  are  so  characteristic. 

Objections  to  the  corn-meal  theory  and  to  the  colloidal  silica  theory 
are  met  more  or  less  convincingly  by  the  respective  advocates  of  each 
belief,  so  that  it  is  perhaps  best  for  the  present  to  consider  the  matter 
undecided. 

Spring  and  fall  are  the  seasons  of  greatest  incidence  of  pellagra  and 
similarly,  these  are  the  times  for  recurrences  of  the  disease  in  aggra- 
vated form,  once  it  has  gained  a  foot-hold  in  a  given  subject.  Most 
of  the  patients  are  between  the  ages  of  twenty  and  forty  years  and  only 
about  9  per  cent,  are  under  the  age  of  fifteen  years.  Cases  observed 
in  infants  have  never  been  proved  in  any  degree  hereditary. 


PELLAGRA  739 

Pathology. — The  skin  lesions  exemplify  changes  varying  from  an 
early  erythema-like  sunburn  to  thickening,  pigmentation,  and  atrophy. 
Except  for  atrophic  changes  in  the  gastro-intestinal  tract  and  fatty 
degeneration  of  the  viscera,  the  most  pronounced  additional  effects 
of  the  disease  are  confined  to  the  spinal  cord  and  brain.  There  is  an 
endothelial  proliferation  in  the  capillaries  of  the  pia  with  some  connect- 
ive tissue  increase,  together  with  diminution  in  the  nerve  cells  of  the 
cortex  and  a  considerable  degree  of  gliosis.  In  the  cervical  cord  the 
posterior  columns  show  degeneration  and  in  the  dorsal  region,  the 
lateral  columns  are  similarly  affected. 

Symptomatology. — Following  a  prolonged  "incubation"  period 
marked  by  malaise,  the  average  pellagrin  gives  evidence  first  of  digestive 
disorder.  This  is  indicated  by  redness  and  coating  of  the  tongue 
frequently  combined  with  actual  stomatitis,  flatulence  and  abdominal 
cramps,  and  diarrhea.  At  some  period  the  last-named  symptom  oc- 
curs in  fully  85  per  cent,  of  cases.  Almost  as  soon,  if  not  equally  early, 
the  skin  on  the  exposed  parts  of  the  body  becomes  the  seat  of  an  eryth- 
ema which  develops  into  actual  dermatitis.  After  a  few  weeks  this  in- 
jflammation  subsides,  leaving  the  integument  bronzed  and  indurated 
over  a  period  of  possibly  many  months.  Mental  derangement  is  com- 
mon but  this  symptom  in  children  calls  for  only  passing  mention.  Ver- 
tigo and  headache  are  not  infrequent  and  many  patients  show  a 
positive  Romberg  test,  and  in  ocular  examination,  changes  in  the  retina 
and  anomalies  in  the  fundus  reflex.  The  lower  tendon  reflexes  are 
usually  exaggerated  but  are  at  times  diminished.  The  disease  ordi- 
narily runs  a  sub-acute  or  chronic  course  with  a  tendency  into  sub- 
sidence during  summer  and  winter  with  recurrences,  as  has  been 
noted,  during  spring  and  fall.  At  these  periods  renewed  severity  in 
the  skin  and  gastro-intestinal  symptoms  is  the  rule.  Rises  of  tem- 
perature are  not  common.  Malnutrition  and  anemia  are  invariably 
present,  but  the  changes  in  the  blood  are  in  no  way  pathognomic. 
As  a  rule  there  is  with  the  anemia,  a  slight  leucocytosis  and  a  moderate 
mononucleosis  of  from  10  to  20  per  cent.  The  urine  contains  an 
excess  of  indican. 

Prognosis. — In  children  pellagra  is  ordinarily  less  severe  than  in 
adults.  The  adult  mortality  in  the  white  race  is  estimated  at  27  per 
cent.  Complicating  diseases  including  principally  tuberculosis,  ma- 
laria and  hook-worm  disease,  doubtless  contribute  to  this  high 
mortality.  Notwithstanding  the  tendency  of  the  disease  to  run  a 
chronic  course  over  months  and  years,  occasional  acute  cases  are 
observed  which  prove  fatal  in  as  short  a  time  as  a  fortnight. 

Diagnosis. — Pellagra  may  at  times  be  confounded  with  eczema, 
scurvy,  dysentery,  tuberculosis  and  leprosy.  The  character  and  dis- 
tribution of  the  cutaneous  lesions,  the  significant  digestive  disturbances, 
the  peculiar  course  of  the  disease,  and  the  history  of  other  cases  in  the 
locality  where  the  patient  has  resided  are  the  points  of  greatest  value 
in  reaching  conclusions  in  a  given  case. 

Treatment. — Preventive    measures    under    Health    Department 


740  THE    PRACTICE    OF    PEDIATRICS 

supervision  are  essential  in  all  communities  where  pellagra  is  endemic. 
Rules  to  govern  the  care  and  sale  of  corn  in  such  communities  are 
justifiable  even  though  spoiled  maize  shall  be  proved  to  have  no  part 
in  the  causation  of  the  disease.  In  view  of  the  findings  of  Alessan- 
drini  and  Scala,  drinking  water  should  be  provided  which  is  free  from 
excessive  quantities  of  colloidal  silica.  All  cases  of  the  disease  should 
be  reported  and  given  opportunity  at  least  to  have  the  advantage  of 
institutional  care.  Goldberger  recommends  a  diet  rich  in  legumes  and 
animal  proteins,  comprising  milk,  eggs  and  meat.  Baths,  salt  rubs 
and  massage  are  of  special  value  in  the  management  of  cases  in  chil- 
dren. Most  authorities  administer  arsenic,  up  to  the  physiological 
limit  with  intermissions  of  a  few  days  at  stated  periods.  Fowler's 
solution,  atoxyl,  and  sodium  cacodylate,  are  the  preparations  of  choice. 
The  last  of  these  has  been  administered  intramuscularly  with  good 
results  by  Deaderick  and  Thompson  in  dosage  of  three  grains  daily 
for  an  adult.  Quinine  hydrobromate  has  received  particular  ad- 
vocacy from  Dyer.  Serotherapy  consisting  in  injections  of  serum 
from  cured  patients  in  healthy  individuals,  horse  serum  specially 
prepared  according  to  the  method  of  Nicolaier  or  serum  from  the 
patient  himself  (autoserotherapy)  has  given  favorable  results  in  a 
number  of  instances. 

Alessandrini  and  Scala  believe  the  specific  treatment  is  the  ad- 
ministration of  alkali  to  combat  the  acid  intoxication  produced  by 
silica.  The  preparation  of  choice  is  sodium  citrate,  and  this  they  ad- 
minister hypodermatically  in  a  10  per  cent,  solution.  Oral  admin- 
istration has  also  been  found  by  them  to  be  effective.  Sodium 
bicarbonate  may  also  be  given  freely. 

With  any  form  of  specific  therapy  symptomatic  treatment  must 
be  employed  and  this  demands  the  use  of  local  applications  for  the 
skin  lesions,  intestinal  astringents  and  antiseptics,  and  mouth  washes, 
preferably  containing  chlorate  of  potash.  Concurrent  diseases 
such  as  hook-worm  disease,  and  malaria  should  above  all  not  be 
neglected. 

BERffiERI 

Beriberi  is  a  disease  the  leading  characteristics  of  which  are  mul- 
tiple neuritis  and  general  cedema.  The  disease  occurs  in  individuals 
whose  food  is  deficient  in  certain  vitamins. 

Etiology. — Beriberi  is  most  common  among  rice-eating  Oriental 
peoples  but  is  endemic  also  in  Brazil.  The  prevailing  view  held  for  a 
considerable  time  was  that  the  specific  cause  was  a  microorganism 
which  elaborates  a  toxin  productive  of  neuritis.  This  view  has  now 
given  place  to  the  theory  of  food  deficiency.  Thus  in  the  last  two  de- 
cades it  has  been  established  that  the  disease  is  prevalent  only  among 
peoples  subsisting  largely  on  a  diet  of  rice  which  is  "polished"  or 
highly  milled.  The  removal  of  the  husk  of  the  rice  with  the  subjacent 
layer  containing  protein  and  fat  leaves  little  but  the  starch  and  such 
rice  has  been  shown  to  be  deficient  in  anteneuritis  vitamin  and  phos- 


BERIBERI  741 

phorus.  The  phosphorus  pentoxid  content  is  more  or  less  directly 
proportionate  to  the  amount  of  vitamin  present  and  rice  containing 
less  than  0.4  per  cent,  of  P2O5  will  cause  beriberi  whereas  rice  contain- 
ing more  than  0.4  per  cent,  will  prevent  beriberi.*  Lack  of  vitamin  in 
other  starch  food  may  similarly  be  responsible  for  the  disease  in  people 
who  do  not  eat  rice,  but  subsist  on  a  similar  unbalanced  ration. 
Overheating  of  food  destroys  the  vitamin. 

Symptoms. — The  leading  manifestations  are  multiple  neuritis 
and  edema.  When  paralysis  predominates,  the  term,  dry  or  atrophic 
beriberi  is  applied  to  the  disease,  if  the  oedema  is  pronounced,  the 
term  wet  beriberi  is  employed.  Fever  is  seldom  noted.  Progressive 
asthma,  weakness  in  the  legs,  cardiac  palpitation  and  shortness  of 
breath  constitute  the  early  manifestations.  With  the  progress  of  the 
affection,  symptoms  of  multiple  neuritis  become  apparent,  such  as 
localized  sensory  and  motor  disturbances,  coincidently  localized  edema 
develops  in  the  extremities.  Edema  in  the  serous  cavities  of  the  body 
may  follow.  Nausea,  vomiting  and  epigastric  discomfort  are  common. 
Eventually  foot  drop,  wrist  drop  and  atrophy  of  the  muscles  affected 
by  the  neuritis  develop.  Blood  examination  reveals  only  the  exist- 
ence of  a  simple  anemia.  The  urine  may  contain  albumin  but  seldom 
shows  the  presence  of  elements  indicative  of  nephritis.  Special  forms 
of  beriberi  are  the  rudimentary  type,  the  fulminating  or  pernicious 
form  and  infantile  beriberi.  The  last  type  develops  in  infants  of 
mothers  who  have  the  disease  and  is  characterized  by  vomiting,  oedema 
and  symptoms  of  cardiac  failure. 

Diagnosis. — Sporadic  cases  may  be  difficult  of  diagnosis.  In 
children  beriberi  may  be  confused  with  nephritis,  alcoholic  neuritis 
and  the  neuritis  of  diphtheria.  The  habits  of  life  of  the  patient,  the 
distribution  of  the  paralysis,  and  the  urinary  signs  aid  principally  in 
confirming  a  doubtful  diagnosis.  Leprosy  accompanied  by  neuritic 
manifestations  is  at  times  mistaken  for  beriberi. 

Prognosis. — The  death  rate  varies  markedly  in  different  epidemics, 
ranging  from  2  per  cent,  among  Japanese  soldiers  who  were  treated  in 
military  hospitals  to  as  high  as  50  or  60  per  cent,  among  un- 
treated and  ignorant  peoples.  In  individual  cases  the  prognosis 
should  be  guarded  as  in  cases  of  post-diphtheritic  paralysis  because 
of  the  constant  danger  of  sudden  cardiac  failure. 

Treatment. — Prophylaxis  is  most  important.  A  well-balanced 
diet  is  sufficient  to  prevent  the  disease  in  an  individual  who  will  ob- 
serve the  ordinary  laws  of  hygiene.  Nursing  mothers  who  have  the 
disease  should  promptly  be  made  to  cease  nursing.  Treatment  of  the 
developed  disease  is  largely  symptomatic.  The  diet  should  be  light 
but  nutritious,  and  contain  the  elements  lacking  in  polished  rice. 
Brewer's  yeast,  powdered  rice  husks  and  adzucki  and  mango  beans 
are  among  the  articles  recommended  as  favorable  to  a  cure.  Rice 
itself  should  be  removed  from  the  diet.  Saline  laxatives  are  of  great 
value  and  the  use  of  these  should  be  supplemented  with  the  admin- 
*  Barker — Monographic  Mediciue,  vol.  iv.,  p.  777. 


742  THE    PRACTICE    OF    PEDIATRICS 

istration  of  diuretics  such  as  potassium  citrate  or  even  diuretin.  Car- 
diac stimulants  which  do  not  upset  the  stomach  are  of  value  at  times 
but  the  routine  use  of  digitahs  has  few  advocates.  For  the  vomitmg, 
small  doses  of  morphine  are  permissible  if  bromide  proves  ineffectual. 
As  soon  as  oedema  disappears  affected  extremities  should  be  treated 
by  passive  movements,  massage  and  electricity.  Complete  change  of 
climate  and  environment  does  most  to  promote  convalescence. 


XVIII.  MISCELLANEOUS  SUBJECTS 
HEREDITY  AND  ENVIRONMENT 

Many  of  the  diseases,  crimes,  and  failures  of  life  are  attributed  to 
heredity,  as  are  also  vigor  of  body,  attainments,  and  successes.  Hered- 
ity and  environment  are  two  important  determining  factors  in  the 
life  of  the  child.  Both  exert  their  influence  over  the  individual.  I  had 
been  taught,  or  in  some  way  conceived  the  idea,  that  the  influence  of 
heredity  was  predominant;  but  as  a  result  of  the  closest  association 
with  developing  children,  coming  into  intimate  relations  with  hundreds 
of  them  and  watching  carefully  their  physical  and  mental  development, 
the  great  influence  exerted  by  environment,  which  often  means  only 
opportunity,  has  been  forced  upon  me.  It  relegates  heredity  to  the 
background.  That  certain  diseases,  such  as  syphilis  and  hemophilia 
may  be  transmitted  from  parent  to  child  is  undisputed;  that  certain 
physical  states — the  so-called  constitutional  vices — may  also  be  trans- 
mitted is  indisputable;  but  that  much  of  natural  phj^sical  weakness 
and  hereditary  tendencies  may  be  overcome  by  the  beneficial  influence 
of  environment  is  now  universally  acknowledged.  Heredity  without 
favorable  environment  counts  for  little.  Place  a  child  or  one  of  the 
lower  animals,  with  an  ideal  heredity,  under  unfavorable  conditions 
of  environment  and  the  favorable  heritage  counts  for  little.  Feeding, 
care,  and  general  good  management  shape  physical  future  much  more 
than  does  inheritance.  In  proof  of  supposed  inherited  mental  traits, 
the  offspring  of  criminals  or  drunkards  are  pointed  out  as  showing 
how  children  follow  in  the  footsteps  of  their  fathers  and  mothers.  It 
must  be  admitted  that  here  the  hereditary  influence  is  bad,  but  one 
should  remember  that  the  environment  has  also  been  very  unfavorable. 

Mental  traits  much  more  than  physical  conditions  are  apt  to  have 
an  influence  on  the  progeny,  although  here,  again,  brilliant  fathers 
rarely  transmit  their  higher  mental  powers  to  their  offspring,  as  is 
proved  again  and  again  in  the  professional  and  business  world.  Many 
of  the  ills  laid  at  the  door  of  heredity  are  due  to  errors  in  early  manage- 
ment. In  the  breeding  of  animals  great  stress  is  laid  upon  pedigree, 
and  credit  is  given  accordingly.  It  should  be  remembered,  however, 
that  the  stock-raiser  appreciates  the  value  of  the  young  of  his  herds, 
and  they  invariably  get  the  care  that  is  best  calculated  to  develop  the 
perfect  animal,  which  is  exactly  what  the  majority  of  the  children  of 
the  human  family  do  not  get.  A  well-bred  animal,  treated  from  birth 
to  maturity  as  are  many  children,  would  cut  a  sorry  figure  in  the  animal 
world. 

Hereditary  influences  in  animals  are  much  more  apt  to  obtain  be- 
cause of  the  comparatively  short  period  of  growth  from  infancy  to  ma- 

743 


744  THE    PRACTICE    OF    PEDIATRICS 

turity.  The  age  of  puberty  in  the  lower  animals  is  reached  in  most 
instances  before  the  first  year.  In  the  human  the  development  is  much 
slower,  supplying  a  much  longer  time  for  the  influences  of  environment 
to  make  their  impress  upon  the  individual. 

CONSANGUINITY 

Much  has  been  made  of  the  supposed  unfavorable  influences  exerted 
upon  the  offspring  by  parents  closely  related  by  blood.  Consanguine- 
ous marriages,  according  to  my  observation,  exert  very  little  influence 
on  the  progeny  if  both  the  parents  are  in  good  health. 

Because  the  parents  of  animals  or  children  are  closely  related,  it 
does  not  follow  that  the  offspring  must  or  will  show  mental  or  physical 
deterioration.  If  there  is  a  decided  family  taint  or  weakness,  the  tend- 
ency toward  this  weakness  would  be  exaggerated  in  the  offspring.  I 
have  known  first  cousins  to  marry  and  have  perfectly  normal  children. 
In  two  instances  under  my  observation  fathers  have  impregnated  their 
own  daughters  and  normal  children  were  the  outcome.  In  the  animal 
world  the  close  breeding  of  brothers  and  sisters  and  parent  and  off- 
spring under  my  own  observation  was  followed  by  normal  vigorous 
young  animals.  Doubtless  if  this  in-breeding  were  continued  through 
successive  generations  the  outcome  would  be  disastrous. 

TEMPERATURE  IN  CHILDREN 

Normal  Temperature. — The  question  is  often  asked:  What  is  the 
normal  temperature  of  a  baby  or  young  child  of  a  given  age?  In  order 
to  answer  this  question  from  our  own  observation,  a  study  of  the  matter 
was  carried  out  at  my  suggestion  by  Dr.  H.  G.  Myers,  resident  physi- 
cian at  The  New  York  Infant  Asylum.  This  study  comprised  59  cases, 
the  ages  varying  from  birth  to  one  year.  Only  well  children  were 
selected  for  the  observation,  the  majority  being  breast-fed.  The  tem- 
peratures in  each  instance  were  taken  by  the  rectum  for  four  minutes. 

It  was  found  that  the  birth  temperature  in  these  infants  ranged 
from  96°  to  98°F.,  exceeding  98°F.  in  but  five  cases,  when  it  was  be- 
tween 98°  and  99°F.  In  one  it  was  94°F.  During  the  twenty-four 
hours  following  birth  there  was  a  rise  in  the  temperature  usually  of 
about  one  degree.  From  this  time  on  there  was  little  variation  in  the 
temperature,  when  the  child  was  well,  regardless  of  the  age.  There 
would  be  a  variation  at  different  times  of  the  day  of  a  fraction  of  a  de- 
gree, the  temperature  being  higher  in  the  evening.  Upon  looking  over 
the  charts  upon  which  the  results  were  chronicled,  one  is  impressed  by 
the  uniformity  of  the  temperature,  which  ranges,  within  fairly  narrow 
limits,  from  98°  to  99.2°F. 

Instances  when  the  temperature  arose  to  99.5°F.  were  occasionally 
seen,  but  100°F.  was  very  unusual.  It  is  not  claimed  that  the  tempera- 
ture of  a  well  child  may  not  reach  100°F. ;  in  fact,  there  were  occasions 
when  it  rose  to  101°F.  and  illness  could  not  be  proved,  and  had  not  the 


TEMPERATURE    IN    CHILDREN  745 

temperature  been  taken  for  the  purpose  above  mentioned,  no  elevation 
would  have  been  suspected,  for  when  next  taken  the  temperature  was 
normal.  In  these  cases  in  which  a  rise  was  proved  to  be  an  early  sign 
of  illness,  the  recording  of  the  temperature  was  discontinued  and  the 
first  reading  was  not  included  in  the  observations.  In  one  child  a  tem- 
perature of  103°F,  was  found.  It  remained  at  this  point  for  three 
hours,  when  it  fell  to  normal  without  any  other  manifestation  of 
trouble.  When,  however,  the  thermometer  registered  over  99.5°F., 
some  cause  for  the  elevation  could  usually  be  discovered;  though  it  may 
have  been  nothing  more  than  excitement  or  slight  indigestion. 

Several  years  ago  I  personally  made  a  similar  series  of  observations 
at  the  Country  Branch  of  the  New  York  Infant  Asylum  upon  25 
healthy  children  under  eighteen  months  of  age.  The  temperatures 
were  taken  four  times  a  day,  the  observations  extending  over  an  entire 
week.  It  was  found  that  in  these  well  children  the  temperature  varied 
from  98°  to  99°r.;  and  that  when  it  rose  daily  above  99.5°F.,  some 
abnormal  condition  was  always  found  to  explain  it. 

From  these  observations  upon  74  well  children,  ranging  in  age  from 
birth  to  eighteen  months,  whose  temperatures  were  taken  several 
hundred  times,  it  would  seem  that  a  daily  rise  above  99.5°F,  may  be 
considered  abnormal.  An  occasional  rise,  however,  considerably  higher 
than  this,  as  above  mentioned,  may  occur  and  does  occur  in  perfectly 
healthy  children,  without  any  special  significance. 

Fever. — By  fever,  then,  in  infants  and  children  we  understand  an 
increase  above  that  which  is  considered  the  normal  body-temperature. 

In  children,  for  clinical  purposes,  the  rectal  temperature  should 
always  be  taken.  With  those  under  five  years  of  age  the  mouth  ob- 
servation is  unsafe,  because  the  child  is  apt  to  bite  off  the  thermometer 
bulb,  and  unreliable,  because  the  lips  will  not  remain  closed  the  requi- 
site three  or  four  minutes.  The  axillary  temperature  is  thoroughly 
misleading  and  should  never  be  depended  upon.  Thermometers 
should  be  carefully  disinfected  with  alcohol  after  using.  One-minute 
thermometers,  according  to  my  observations,  are  often  unreliable  and 
should  not  be  used. 

Hyperpyrexia. — The  highest  temperature  personally  known  to  the 
writer  was  111°F.  This  was  as  high  as  the  thermometer  could  register. 
It  occurred  in  a  child  of  ten  months  who  was  in  a  convulsion  which  was 
one  of  the  first  symptoms  of  a  tuberculous  meningitis.  The  child  had 
been  placed  by  the  parents  in  water  at  a  temperature  of  115°F.,  and 
had  been  in  the  water  about  ten  minutes  before  the  rectal  temperature 
was  taken.  How  much  the  temperature  was  due  to  the  illness  and  how 
much  to  the  hot  water  will  never  be  known.  The  temperature  re- 
sponded promptly  to  a  cold  bath.  The  child  never  regained  conscious- 
ness and  died  of  meningitis  ten  days  after  the  initial  convulsion. 

Fever  as  an  Indication. — Fever  may  or  may  not  be  an  index  of  the 
gravity  of  a  disease.  Thus  we  frequently  see  a  temperature  ranging 
from  103°  to  105°F.  in  tonsillitis,  acute  indigestion,  and  stomatitis — 
ailments  which  respond  very  quickly  to  treatment  and  which  present 


746  THE    PRACTICE    OF    PEDIATRICS 

no  serious  aspects.  In  typhoid  fever,  pneumonia,  scarlet  fever,  and 
diphtheria,  however,  when  the  temperature  range  is  above  104°F., 
it  is  a  symptom  of  considerable  value,  as  indicating  the  severity  of  the 
infection.  It  is,  therefore,  not  the  fever  itself,  but  the  condition  back 
of  and  associated  with  it,  which  makes  it  a  sign  of  clinical  value.  In 
pneumonia  children  bear  a  comparatively  high  temperature,  104°F., 
for  example,  without  much  discomfort  or  danger;  while  in  the  acute 
intestinal  disorders  of  summer  an  equal  degree  of  fever  is  borne  very 
badly,  and  if  continued  is  of  grave  significance.  This  must  be  kept  in 
mind  in  our  dealings  with  fever. 

Im/portance  of  Hyperpyrexia. — When  is  a  given  temperature  to  be 
interfered  with,  is  a  question  which  concerns  all  practitioners.  This 
depends  to  a  great  extent  upon  the  cause  of  the  fever  and  its  effects 
upon  the  patient.  If  the  fever  produces  diminished  assimilation,  loss 
of  sleep,  irritability,  and  restlessness,  it  will  do  the  child  harm  by  di- 
minishing the  normal  resistance  to  disease,  and  should  be  relieved 
whether  it  is  102°F.  or  105°F.  Interference  is  thus  dependent  not  so 
much  upon  the  height  of  the  temperature  as  upon  its  effects  upon  the 
patient. 

The  7nethods  of  relieving  fever  are:  (1)  Elimination:  This  applies 
particularly  to  the  gastro-enteric  tract  and  the  skin.  In  a  majority  of 
the  cases  of  high  fever  due  to  acute  indigestion,  with  resulting  toxemia, 
a  purgation,  a  bowel- washing,  and  a  carefully  adjusted  diet  for  a  day 
or  two  secure  recovery.  We  remove  the  cause  of  a  fever,  and  the  fever 
subsides.  Unfortunately,  this  means  of  controlling  fever  is  limited  to 
the  gastro-enteric  tract.  (2)  Diaphoresis,  by  which  is  understood  the 
production  of  an  excessive  perspiration,  will  also  relieve  high  tempera- 
ture. The  m.ost  reliable  way  of  bringing  this  about  in  a  child  is  by  the 
use  of  moderately  heavy  covering  and  the  administration  of  the  tincture 
of  aconite,  in  doses  of  one-half  to  one  drop  every  hour — eight  doses  in 
twenty-four  hours;  or  liquor  ammonii  acetatis,  two  drams  every  two 
hours,  for  a  child  one  year  old.  (3)  Hydrotherapy:  By  far  the  most 
satisfactory  means  of  controlling  fever  depends  upon  the  local  ab- 
straction of  heat  by  means  of  sponging  (p.  776),  tub-baths  (p.  779),  and 
cool  packs  (p.  777).  (4)  Antipyretic  drugs:  Much  which  borders  on 
the  sensational  has  been  written  about  the  harmfulness  of  antipyretic 
drugs,  particularly  the  coal-tar  products.  Used  in  large  and  frequent 
doses,  they  certainly  may  do  a  great  deal  of  damage;  under  certain  con- 
ditions, used  in  small  doses  and  repeated  at  intervals  of  from  three  to 
six  hours,  they  may  be,  and  often  are,  of  benefit.  Aconite  and  liquor 
ammonii  acetatis  are  of  some  value,  as  above  stated,  but  they  are  of 
little  value  in  controlling  a  very  high  persistent  temperature.  The 
coal-tar  products  furnish  the  best  antipyretic  drugs  and  may  be  used 
with  safety,  but  should  be  used  only  when,  for  any  reason,  the  local 
abstraction  of  heat  by  the  application  of  cold  is  impossible.  In  many 
families  there  is  too  little  intelligence  to  make  a  cold  pack  either  possi- 
ble or  safe.  In  severe  cases  of  pneumonia  and  scarlet  fever,  and  in  the 
intestinal  diseases,  sponging  often  will  not  answer.     Only  a  trained 


OBSCURE   ELEVATION   OF  TEMPERATURE  747 

nurse  or  a  very  intelligent  mother  should  be  intrusted  with  a  pack. 
Moreover,  sponging  and  tub-bathing,  if  repeated  too  frequently,  par- 
tieularl}^  during  the  night,  exhaust  the  child.  Sponging  or  tub-baths 
are  often  strenuously  objected  to  by  parents  as  well  as  by  the  patient, 
and  if  the  nurse  is  one  of  the  family,  her  sympathy  will  counterbalance 
her  judgment,  and  the  result  be  far  from  satisfactory.  Under  such  con- 
ditions, when  the  application  of  cold  to  the  skin  is  impossible,  a  combi- 
nation of  phenacetin  and  caffein,  alone  or  with  Dover's  powder,  has 
proved  effective.  The  antipyretic  treatment  of  scarlet  fever  is  the 
same  as  that  of  pneumonia  or  typhoid  fever. 

My  use  of  antipyretic  drugs  has  been  confined  almost  entirely  to  the 
ignorant  in  private  work  and  to  dispensary  patients.  To  a  child 
of  one  year  or  under,  one  grain  of  phenacetin  with  3^  grain  of  citrate  of 
caffein  maybe  given  and  repeated  at  three-hour  intervals  if  the  tempera- 
ture requires  it;  to  a  child  two  years  of  age  1}^  grains  of  phenacetin 
and  }'2  grain  of  citrate  of  caffein  at  three-hour  intervals;  three  years 
and  over,  13-^  to  23-^  grains  of  phenacetin  with  }-2  to  1  grain  of  citrate  of 
caffein,  at  intervals  of  from  three  to  six  hours.  If  there  is  much  rest- 
lessness and  irritability,  which  is  not  thus  controlled,  Dover's  powder 
may  be  added — 3^  grain  to  each  dose,  for  a  child  of  from  three  to  six 
months  of  age;  }4,  grain  between  six  and  twelve  months;  1  grain  after 
the  age  of  two  years  is  reached.  It  is  always  wise  to  caution  parents  as 
to  the  use  of  Dover's  powder.  They  should  be  told  that  if  the  child 
becomes  ''heavy"  or  unusually  sleepy,  the  powders  must  be  discon- 
tinued. That  phenacetin  and  citrate  of  caffein  cannot  be  given  in  solu- 
tion is  unfortunate.  Like  all  insoluble  powders,  they  are  best  given 
in  some  mucilaginous  mixture,  such  as  barley-water  or  one  of  the 
cereal  jellies.  Fruit-juice  or  apple-sauce  usually  answers  well.  Anti- 
pyrin,  for  the  reason  that  it  forms  a  tasteless  mixture  with  water, 
succeeds  better  with  some  intractable  children,  and  may  be  used  in  the 
same  doses  as  phenacetin,  although  as  an  antipyretic  the  antipyrin  is 
less  efficient. 

OBSCURE  ELEVATION  OF  TEMPERATURE 

Perhaps  the  most  annoying  cases  in  pediatric  work  are  those  with  an 
elevation  of  the  temperature  for  which  no  adequate  cause  can  be  dis- 
covered. In  the  section  on  Normal  Temperature  certain  possible 
variations  are  given  which  I  regard  as  within  the  limits  of  health. 
When  these  boundaries  are  passed,  when  there  is  a  temperature  range 
between  99°  and  101°  or  102°F.,  or  a  temperature  persistently  at  100° 
or  101°F.  without  any  apparent  cause,  and  continuing  for  days  and 
weeks,  the  medical  adviser  is  not  in  an  enviable  situation.  Such  cases 
coming  to  the  pediatrist  through  consultation  or  otherwise  are  some- 
times easy  of  solution.  At  other  times,  however,  the  cause  of  the  fever 
may  never  be  discovered,  and  the  patient  eventually  gets  well,  leaving 
us  still  in  ignorance  of  the  cause. 

Active  Exercise  in  Nervous  Children. — This  is  not  infrequently  the 


748  THE    PRACTICE    OF    PEDIATRICS 

cause  of  an  elevation  of  the  temperature.     I  have  seen  several  cases  of 
this  nature. 

A  few  years  ago  I  saw  in  consultation  a  country  child  three  years 
of  age  whose  temperature  every  afternoon  at  one  o'clock  was  102°F. 
The  child,  while  not  vigorous,  showed  no  signs  of  illness.  He  ate  well, 
slept  well,  and  played  hard.  There  was  a  slow  gain  in  weight.  The  fever 
was  discovered  by  the  mother,  who  thought  that  the  child,  who  was  a 
blonde,  looked  flushed  every  day  at  about  the  same  time.  The  tem- 
perature by  rectum  was  normal  in  the  morning  and  normal  at  night. 
This  condition,  to  the  attending  physician's  knowledge,  had  persisted 
for  six  weeks  before  I  saw  the  patient.  How  long  there  had  been  a  daily 
elevation  of  the  temperature  above  the  normal  before  the  mother  dis- 
covered it  we  have  no  means  of  knowing.  The  doctor,  an  excellent 
practitioner,  had  suspected,  examined  the  child  for,  and  treated  him 
for,  various  diseases ;  the  first  being  malaria,  with  no  response  to  quinin ; 
then  typhoid  fever,  as  by  suggestion  and  constant  inquiry  the  child 
came  to  imagine  that  he  must  be  sick,  and  complained  of  languor.  The 
fever  continued,  however,  beyond  the  usual  time  allowance  for  typhoid 
fever  and  there  were  no  other  symptoms.  There  was  no  enlargement 
of  the  spleen  and  the  blood  had  been  repeatedly  found  negative  to  the 
Widal  reaction.  Other  possible  causes  of  the  fever  were  also  given  at- 
tention. One  day  the  doctor  suggested  tuberculosis.  This  aroused 
the  family  and  friends  and  a  consultation  was  the  immediate  result.  In 
company  with  the  doctor,  I  saw  the  child  at  his  home.  I  found  a 
rather  thin  boy,  three  years  old.  The  family  history  was  excellent. 
There  was  one  other  child,  six  years  of  age,  who  was  well  and  a  good 
specimen  of  robust  boyhood.  The  patient  had  never  had  a  pulmonary 
disorder  and  no  disease  of  the  respiratory  tract  other  than  slight  bron- 
chitis. There  was  no  apparent  association  of  the  condition  with  any 
intestinal  or  infectious  disease.  An  exhaustive  physical  examination 
failed  to  reveal  any  abnormality  other  than  a  small  umbilical  hernia 
and  a  slight  enlargement  of  the  inguinal  and  submaxillary  glands.  The 
blood  was  not  examined.  The  child  was  pale,  and  doubtless  a  blood 
examination  would  have  revealed  a  mild  secondary  anemia.  The 
appetite  was  fairly  good;  the  bowels  were  reported  regular  and  his 
stools  normal.  The  child  had  not  been  kept  in  bed,  as  the  family  did 
not  consider  him  very  ill.  The  physical  examination  being  negative,  I 
questioned  the  mother  very  closely  as  to  the  child's  habits  of  life.  I 
found  that  he  rose  at  7  a.  m.,  had  breakfast  at  7.30,  and  played  with  his 
big  brother  and  two  older  boys  until  1  o'clock,  when  he  had  dinner.  A 
glass  of  milk  and  a  piece  of  bread  and  butter  were  given  as  a  luncheon 
at  11  A.  M.  I  found  that  he  played  very  actively,  kept  up  with  the 
older  boys,  and  was  unhappy  when  he  was  not  with  them.  Attempts 
had  been  made  without  success  to  entertain  him  with  less  strenuous 
play.  It  was  at  midday,  sometimes  before,  sometimes  after  dinner, 
that  the  temperature  reached  the  highest  point.  It  seemed  to  me  that 
here,  probably,  was  a  case  of  fatigue  temperature.  I  accordingly  sug- 
gested that  the  boy  be  undressed  and  put  to  bed  at  11.15  a.  m.  after 


OBSCURE   ELEVATION   OF  TEMPERATURE  749 

the  light  luncheon  and  be  made  to  rest  and  sleep  if  possible.  At  1.15 
he  was  to  be  taken  up  for  dinner,  his  temperature  first  being  taken. 
These  instructions  were  faithfully  carried  out,  and  this  ended  the  daily- 
rise  in  temperature.  The  case  was  one  of  an  active,  nervous  child 
becoming  over-tired  in  his  attempts  to  hold  his  own  with  older  and 
stronger  boys.  The  patient  improved  rapidly  in  his  physical  condition 
and  is  now,  after  an  interval  of  several  years,  perfectly  well. 

Another  child,  four  years  of  age,  was  seen  in  consultation  with  a 
New  York  physician,  because  of  a  daily  elevation  of  the  temperature 
ranging  from  100°  to  102.5°F.,  which  had  continued  for  six  weeks. 
The  child  was  thriving  and  otherwise  perfectly  well  No  cause  for  the 
fever  could  be  discovered  in  his  physical  condition.  He  had  a  noisy, 
excitable  nurse,  who  was  inclined  to  exciting  games  and  rough  play  with 
the  boy.     With  dismissal  of  the  nurse  the  fever  ceased. 

Otitis. — Persistent  fever,  following  the  acute  catarrhal  affections 
of  the  upper  respiratory  tract  and  the  exanthemata,  is  sometimes  ex- 
plained by  a  suppurative  process  in  the  middle  ear,  without  other 
symptoms  than  the  fever. 

Encysted  Empyema. — A  small  area  of  encysted  empyema  may  ex- 
plain a  persistent  fever  following  pneumonia.  Holt  describes  a  most 
interesting  case  of  this  nature  in  which  there  was  for  over  four  weeks  a 
temperature  range  from  100°  to  105°F.  Autopsy  showed  a  small 
collection  of  pus  between  the  diaphragm  and  the  lung. 

Periodic  Fever. — Not  infrequently  we  see  cases  which  show  some 
of  the  clinical  signs  of  malaria  as  regards  periodicity  in  the  temperature, 
but  without  splenic  enlargement  or  the  presence  of  the  malarial  organ- 
ism in  the  blood.  Yet,  often,  these  cases  quickly  respond  to  full  doses 
of  the  bisulphate  of  quinin. 

Typhoid  Fever. — Occasionally,  a  low  persistent  temperature  eleva- 
tion, obscure  for  a  week  or  two,  proves  to  be  due  to  a  mild  typhoid. 

Tuberculosis. — An  elevation  of  the  temperature  is  sometimes  the 
first  premonitory  symptom  of  tuberculosis.  Tuberculosis  in  a  child, 
however,  is  usually  an  active  process  when  it  involves  the  lungs,  and 
can  readily  be  made  out.  When  other  parts  are  involved,  such  as  the 
bones,  glands,  skin,  or  peritoneum,  the  manifestations  are  usually 
sufficiently  plain  to  indicate  the  condition. 

Intestinal  Infection. — Intestinal  infection  due  to  chronic  consti- 
pation may  be  the  cause  of  persistent  fever.  In  a  suspected  case, 
in  the  absence  of  bowel  symptoms,  it  is  well  to  give  a  laxative  and 
put  the  child  temporarily  on  a  reduced  diet  consisting  largely  of 
carbohydrates. 

Pyelitis. — Pyelitis  of  mild  degree  may  produce  a  slight  elevation  of 
the  temperature  which  may  be  difficult  of  solution.  Several  speci- 
mens of  the  urine  may  fail  to  reveal  pus.  In  doubtful  cases  the  urine 
should  be  drawn  by  a  catheter  and  examined  by  culture  methods. 

Unexplained  Elevations  of  Temperature. — I  have  known  children 
to  exhibit  an  unexplained  temperature  of  from  100°  to  101. 5°F.  for 
weeks  without  any  other  signs  of  illness.    I  have  employed  all  the  newer 


750  THE    PRACTICE    OF    PEDIATRICS 

diagnostic  laboratory  methods,  and  I  have  seen  such  patients  recover 
without  a  diagnosis.  Of  one  thing,  however,  we  may  rest  assured :  If 
a  competent,  thorough  examination  does  not  reveal  the  cause  of  the 
temperature,  we  are  safe  in  concluding  that  there  is  nothing  of  a  very 
serious  nature  back  of  it. 

Periodic  attacks  of  elevation  of  the  temperature  from  101  to  104, 
explainable  only  on  the  grounds  of  a  disturbed  metabolism  are  occa- 
sionally encountered.  Other  than  acetone  in  the  urine  these  cases  are 
negative  throughout.  The  pyrexia  lasts  four  or  five  days  and  then 
subsides  by  crisis.  The  acetone  is  not  the  result  of  starvation,  and  the 
case  is  not  one  of  true  acidosis. 

Illustrative  Case. — The  history  of  a  case  of  this  kind,  which  gave  me  no  end  of 
trouble  and  annoyance,  may  not  be  without  interest. 

The  patient,  an  eight-year-old  boy,  was  the  only  son  of  a  habitually  anxious 
mother,  who  had  unfortunately  learned  to  use  the  clinical  thermometer.  She  took 
her  boy's  temperature  after  school  one  day  early  in  December.  She  found  that  the 
thermometer  registered  100. 5°F.  I  was  consulted,  saw  the  boy  in  the  evening, 
took  his  temperature  by  mouth,  with  my  own  thermometer,  and  found  it  100. 8°r., 
with  no  other  evidence  of  disease.  He  was  perfectly  normal  in  every  other  respect. 
He  maintained  that  he  felt  well,  did  not  need  a  doctor,  and  wished  to  be  let  alone 
to  study  his  lessons.  The  following  morning  the  temperature  was  100°F. ;  in  the 
evening  it  was  nearly  101  °F.  For  six  weeks  this  temperature  range  continued, 
never  below  100°F.,  never  higher  than  101. 2°F.  The  boy,  against  my  advice,  was 
taken  from  school.  He  was  put  to  bed,  and  a  half-dozen  consultants  saw  him  with- 
out shedding  any  light  on  the  case.  Finally  the  mother  became  reconciled  to 
"doing  nothing"  for  her  son,  and  he  was  taken  to  a  nearby  winter  resort.  I  sug- 
gested to  the  father  that  before  leaving  town  he  should  "accidentally"  drop  the 
thermometer  on  the  hardwood  floor  and  then  refuse  to  have  another  in  the  house. 
This  he  managed  to  do,  straightway.  The  boy  had  an  excellent  time  at  the  winter 
resort,  played  with  his  sled  in  the  snow,  skated  on  the  lake,  fell  through  the  ice 
once  and  received  a  thorough  wetting,  without  harm.  In  three  weeks  he  returned, 
improved  as  much  as  any  city  child  improves  from  a  country  outing.  His  tem- 
perature was  not  taken  during  these  three  weeks  at  the  winter  resort  and  has  not 
been  taken  since,  except  when  there  have  been  evidences  of  illness.  He  is  now 
developing  along  normal  lines  and  is  a  fair  physical  specimen  for  his  age. 

ANESTHETICS 

That  the  use  of  anesthetics  in  children  is  attended  with  consider- 
able danger  is  proved  by  statistics  relating  to  the  subject.  That  the 
greatest  care  and  judgment  should  be  exercised  in  the  selection  of  an 
anesthetic  for  a  child  is  readily  understood. 

Ether  and  Chloroform. — As  a  routine  anesthetic  for  the  young,  ether 
is  preferable  because  of  its  safety.  The  popular  belief  that  chloroform 
is  without  danger  is  an  error  and  not  sustained  by  statistics.  There 
are  conditions,  however,  when  ether  is  contraindicated.  In  cases  in 
which  there  is  bronchial  involvement,  ether  increases  the  bronchial 
secretions  and  produces  a  free  flow  of  saliva,  which  is  liable  to  be  as- 
pirated into  the  lungs.  In  case  of  any  obstruction  to  respiration,  as 
in  laryngeal  diphtheria,  retropharyngeal  abscess,  and  enlarged  glands 
which  may  encroach  upon  the  air-passages,  chloroform,  and  not  ether, 
should  be  employed.  Ether  is  further  contraindicated  in  scarlet 
fever  or  in  nephritis.  In  such  cases  chloroform  is  to  be  selected. 
Chloroform  is  to  be  used  also  for  the  sake  of  convenience,  if  other 
conditions  allow,  in  operations  about  the  mouth  and  the  nose.     Chlo- 


CARCINOMA  751 

reform  is  contraindicated  in  general  weakness,  exhaustion,  collapse, 
and  in  anemia.  Ether  given  by  the  drop  method  should  be  used  in 
these  cases.  Statistics  of  chloroform  anesthesia  show  a  considerable 
mortality  in  operations  for  adenoids  and  enlarged  tonsils.  The  inter- 
ference with  respiration  and  the  sudden  hemorrhage  make  chloroform 
dangerous  in  these  operations.  In  heart  disease  with  imperfect  com- 
pensation any  anesthetic  is  dangerous,  but  ether  by  the  drop  method 
is  the  least  dangerous. 

Nitrous  Oxid  Gas. — Nitrous  oxid  gas,  which  of  late  has  become  very 
popular,  should  be  used  with  caution  in  children  under  two  years  of  age. 
Young  children  are  very  easily  asphyxiated  by  gas;  the  younger  the 
child,  the  greater  the  danger.  Under  two  years  of  age,  sudden  and 
alarming  asphyxia  has  resulted  from  its  use.  It  should  be  used,  there- 
fore, very  sparingly  and  the  patient  watched  most  carefully  for  signs  of 
cyanosis.  The  use  of  gas  in  children  usually  precedes  the  administra- 
tion of  ether,  as  it  renders  the  use  of  the  latter  much  easier  for  the 
patient.  It  is  contraindicated,  however,  in  any  condition  where 
dyspnea  is  present;  in  fact,  in  any  illness  in  which  respiration  is  im- 
peded, gas  is  dangerous.  The  combination  of  gas  and  ether  in  such 
cases  is  not  as  safe  as  chloroform,  which  is  to  be  given  in  a  minimum 
amount  with  oxygen  as  a  safeguard. 

Danger-signals  with  Ether: 

Marked   cyanosis;  stertorous  breathing;  rapid  pulse;  dilated 
pupils;  short,  quick,  gasping  respiration. 
Danger-signals  with  Chloroform: 

Pallor;   ashen   color;  feeble,   shallow  respirations,   gasping  in 
character;   dilated   pupils  and  separation  of  the  eyelids; 
slow,  feeble  heart  action. 
Danger-signals  During  Gas  Administration: 

Cyanosis;  jerking  respirations;  dilated  pupils;  convulsive  move- 
ments of  any  portion  of  the  body. 

Ethyl  Chlorid. — The  use  of  ethyl  chlorid  is  in  the  experimental 
stage.  Statistics  show  quite  a  mortality  from  its  use.  It  should 
never  be  administered  after  unconsciousness  has  set  in.  In  case  the 
condition  of  the  patient  shows  any  of  the  danger-signals,  it  should 
temporarily  or  permanently  be  discontinued  and  some  other  form  of 
anesthetic  substituted. 

CARCINOMA 

Carcinoma  in  children  is  of  very  unusual  occurrence.  I  have  never 
seen  a  case  either  in  hospital  or  private  work. 

Phillipp  has  collected  390  cases  of  carcinoma  reported  in  children 
under  fifteen  years;  among  these  he  found  but  87  which  were  undoubt- 
edly true  cancers.  To  these  he  adds  6  cases,  making  93  cases  of  cancer 
in  childhood.  This  report  was  published  in  1907.  In  1911  Ribbert 
stated  that  no  other  cases  had  come  under  his  notice,  so  that  about 
93  cases  of  cancer  (real)   have  been  reported  in  children.      Three- 


752  THE    PRACTICE    OF    PEDIATRICS 

fourths  of  these  occurred  in  older  children,  between  eight  and  fifteen 
years  of  age ;  only  one-fourth  prior  to  eight  years. 

The  incidence  of  sarcoma  for  comparison  is  not  given. 

OBESITY 

Exceedingly  fat  children  will  usually  be  found  to  be  hearty  eaters 
and  of  inactive  habits.  Obesity  is  rarely  a  serious  condition,  and  or- 
dinarily requires  little  more  than  certain  restrictions  in  diet  and  regu- 
larity in  exercise.  Generally,  this  is  not  difficult  to  obtain,  as  the 
patients  are  usually  very  anxious  to  re/duce  the  weight  because  of  the 
attention  they  attract  and  the  remarks  the  condition  occasions  in 
public  places  and  among  school-fellows. 

Treatment. — Diet. — In  such  cases  I  direct  that  all  fatty  foods,  in- 
cluding butter  and  whole  milk,  be  excluded  from  the  diet.  Skimmed 
milk  may  be  given  in  moderation — not  over  one  pint  daily.  A  portion 
of  this  may  be  used  on  the  cereal,  and  the  remainder  as  a  drink.  The 
use  of  sugar,  including  candy  and  sweets  of  all  kinds,  is  to  be  forbidden. 
Saccharin  dissolved  in  the  milk  may  be  used  on  the  cereal  and  in  mak- 
ing stewed  fruits  and  plain  puddings  palatable.  Green  vegetables 
may  be  given  freely.  The  evening  meal  should  be  very  light,  consist- 
ing usually  of  broth,  a  small  amount  of  stale  bread,  and  stewed  fruit. 

Exercise. — During  the  warmer  months  golf,  swimming,  tennis, 
horseback  exercise,  and  the  bicycle  are  advised,  a  definite  time,  in  hours, 
being  prescribed  each  day  for  some  active  physical  exercise.  During 
the  cold  months  roller-skating,  ice-skating,  horseback-riding,  out-of- 
doors  when  possible  and  indoors  on  inclement  days,  when  the  means 
are  at  hand,  together  with  long  walks,  should  occupy  part  of  the  daily 
life.  A  schedule  should  be  prescribed  and  written  out  for  each  day, 
depending  somewhat  upon  the  station  in  life  of  the  patient,  not  only  as 
regards  food,  but  also  as  regards  outdoor  exercise.  In  this  way,  under 
an  established  system  of  living  covering  the  entire  day,  there  will 
result,  if  the  family  cooperate,  a  reduction  of  the  obesity  with  marked 
improvement  in  the  patient's  general  condition. 

Drugs. — The  use  of  thyroid  extract  and  other  drugs  for  the  reduc- 
tion of  weight  in  children  is  not  to  be  advised. 

During  the  treatment  the  child  should  be  weighed  regularly,  as  too 
pronounced  results  are  not  desired. 

HEMATOMA  OF  THE  STERNOCLEIDOMASTOID 

This  condition  is  the  result  of  trauma  which  takes  place  during  de- 
livery. The  muscle  is  torn  as  the  result  of  pulling  by  forceps  or  ma- 
nipulation on  the  part  of  the  accoucheur  in  the  endeavor  to  bring 
down  the  after-coming  head  in  breech  cases. 

The  injury  consists  in  a  rupture  of  the  muscle-fibers  and  blood- 
vessels. A  tumor  forms  within  the  muscle-sheath,  which  may  be  small 
or  large,  involving  the  muscle  structure  in  its  entire  width.     There  is 


HERNIA    AT   THE    UMBILICUS  753 

always  an  associated  contraction  of  the  muscle,  which  places  the  head 
in  the  wry-neck  position,  drawn  toward  the  affected  side.  The  tumor 
is  usually  located  in  the  lower  third  of  the  muscle.  I  have  seen  it  im- 
mediately at  the  attachment  to  the  clavicle. 

The  tendency  of  these  cases  is  toward  complete  recovery.  The 
tumor  is  absorbed,  but  a  shorter  muscle  is  sometimes  left,  which  holds 
the  head  in  the  characteristic  position. 

Treatment. — It  has  seemed  to  me,  in  the  observation  of  a  large 
number  of  cases,  that  massage  hastened  the  absorption  of  the  tumor. 
The  massage  should  be  practised  for  fifteen  minutes  three  times  a  day. 
At  the  same  time  a  moderate  stretching  of  the  muscles  should  be 
attempted  by  rotating  the  head  toward  the  unaffected  side  and  up- 
ward.    All  cases  eventually  make  complete  recoveries. 

HERNIA  AT  THE  UMBILICUS 

Protrusion  of  the  abdominal  wall  at  the  umbilicus  may  be  due  to 
an  improper  development  of  the  blastodermic  layers,  with  non-union 
(exomphalos,  hernia  into  the  umbilical  cord) ;  or  may  result  from  a  true 
fetal  hernia  after  the  umbilicus  is  lined  with  peritoneum,  or  a  hernia 
occurring  after  birth  through  a  weak  umbilical  scar. 

Hernia  of  the  Umbh-ical  Cord 

Morbid  Anatomy. — This  condition  is  a  true  fetal  defect,  due  to  a 
failure  of  union  of  the  blastodermic  layers,  leaving  as  the  anterior  wall 
of  the  abdominal  cavity  a  membrane  covered  with  amnion  externally 
and  with  peritoneum  internally.  Through  this  weakened  parietal  wall 
may  occur  a  protrusion  usually  the  size  of  a  pear  or  an  apple,  but  which 
may  range  from  the  size  of  a  small  finger-tip  to  that  of  a  child's  head. 
The  tumor  is  glistening  and  transparent,  and  shows  through  its  walls 
the  contents  of  the  sac.  These  may  include  any  or  all  of  the  abdom- 
inal contents,  stomach,  liver,  Meckel's  diverticulum,  omentum, 
intestines.  Occasionally  the  child  will  be  born  eviscerated  from  the 
bursting  of  such  a  hernia  in  labor;  and  often  its  occurrence  is  asso- 
ciated with  that  of  a  spina  bifida. 

The  covering  of  this  variety  of  hernia  falls  off  with  the  drying  up 
and  dropping  off  of  the  umbilical  cord.  The  contents  are  thus  exposed. 
If  the  defect  is  small  enough,  it  may  granulate  and  epithelialize ;  but  if 
this  does  not  happen  and  operation  is  not  resorted  to,  peritonitis  and 
death  will  probably  ensue. 

Treatment. — Operation  offers  a  means  of  cure  in  these  cases.  Kindt 
reports  50  cures  in  a  series  of  65  operations. 

The  management,  therefore,  should  not  be  expectant.  In  view  of 
the  good  results  of  operation,  an  attempt  should  be  made  as  soon  as 
possible  after  birth  to  close  the  opening  in  the  abdominal  wall  either 
by  cutting  away  the  sac  in  its  entirety  and  suturing  the  abdominal 
walls  together,  or  by  separating  the  amnion  from  the  peritoneum,  re- 
48 


754 


THE    PRACTICE    OF    PEDIATRICS 


placing  this  and  its  contents  into  the  abdominal  cavity,  and  then  sut- 
uring the  walls. 

Congenital  UMBn.iCAL  Hernia 

Etiology. — This  type  of  hernia  occurs  after  the  closure  of  the  vis- 
ceral layers,  and  is  due  to  pressure  within  the  abdominal  cavity  and 
to  the  comparative  weakness  of  the  upper  part  of  the  umbilical  ring, 
and  to  the  extension  of  peritoneum  surrounding  the  umbilical  vessels, 
which,  forming  a  sac,  directs  the  force  of  the  increased  intra-abdom- 
inal pressure.  It  may  occur  through  the  linea  alba,  just  above  the  um- 
bilical riQg,  either  alone  or  in  conjunction  with  hernia  at  the  umbilicus. 

Prognosis. — The  tumor  is  usually  from  3^  to  1  inch  in  diameter, 
and  may  protrude  as  much  as  13^^  inches.  There  is  seldom  any  discom- 
fort, although  when  the  contents  are  extruded  and  reduced,  there  may 
be  some  pain.  Danger  of  strangulation  is  slight,  and  the  prognosis 
as  regards  cure  is  good.  The  time  required  ranges  from  six  months  to 
two  years.     The  younger  the  child,  the  quicker  the  cure. 


Fig.  111. — Umbilical  hernia  reduced  and  adhesive  plaster  applied. 

Treatment. — Treatment  consists  in  retaining  the  hernia  and  allow- 
ing the  opening  to  close,  and  is,  therefore,  entirely  mechanical.  Opera- 
tion is  rarely  necessary.  Of  2000  operations  for  hernia  in  children 
under  fourteen  years  of  age  at  the  Hospital  for  Ruptured  and  Crippled, 
but  1.3  per  cent,  were  for  umbilical  hernia.  By  far  the  most  effect- 
ive method  of  treatment  is  to  bring  together  over  the  umbilicus  (Fig. 
Ill)  two  folds  of  skin,  so  that  they  meet  in  the  median  line  and  invert 
the  umbilicus.  These  folds  of  skin  thus  form  a  splint  which  is  retained 
by  a  strip  of  moleskin  adhesive  plaster  1  or  2  inches  wide  and  suffi- 
ciently long  to  hold  fast  to  the  skin — usually  about  4  to  6  inches.  This 
method  in  my  hands  has  proved  the  most  satisfactory  and  has  been 
followed  by  the  most  rapid  cures. 

The  objection  to  the  use  of  a  covered  button  or  any  form  of  pad, 
many  of  which  have  been  recommended,  is  that  unless  it  is  very  large 
the  pad  is  apt  to  make  strong  pressure  upon  the  abdominal  opening, 
and  while  keeping  the  hernia  reduced,  prevent  rapid  closure  of  the  ring 


INGUINAL    HERNIA  755 

itself,  A  pad  or  button  may  also  interfere  with  the  circulation  and  thus 
hinder  the  nutrition  of  the  muscles  and  cause  the  weakness  to  persist. 
Umbilical  trusses  and  bandages  have  been  used  repeatedly,  and  all 
have  proved  hopeless  failures,  and  for  one  reason  chiefly — the  dif- 
ficulty of  keeping  them  in  position.  Any  intelligent  mother  or 
nurse  can  be  taught  to  apply  the  plaster  as  suggested  above.  The 
child  may  be  bathed  with  the  plaster  in  position.  Ordinarily,  it  is 
best  to  apply  a  fresh  piece  every  fifth  day.  Irritation  of  the  subjacent 
skin  sometimes  occurs,  and  if  this  tendency  exists,  folds  can  be  made 
at  right  angles  to  those  previously  made  and  the  plaster  applied 
again  at  right  angles  to  the  folds.  By  this  means  the  excoriated  skin 
remains  uncovered. 

INGUINAL  HERNIA 

Inguinal  hernia  is  of  rare  occurrence  in  female  infants,  but  is  com- 
paratively frequent  in  males.  It  may  be  present  at  birth,  or  develop 
at  a  later  period.  The  right  side  is  more  frequently  involved.  Double 
hernia,  however,  is  not  at  all  infrequent. 

Etiology. — Anatomic  Conditions. — The  special  anatomic  condition 
predisposing  to  inguinal  hernia  in  infancy  is  the  short  and  direct  course 
of  the  inguinal  canal.  In  the  infant  the  internal  abdominal  ring  is 
almost  directly  behind  the  external  ring,  and  on  practically  the  same 
level.  Incomplete  closure  of  the  inner  opening,  combined  with  weak- 
ness of  the  peritoneum  in  the  neighborhood  of  the  ring,  thus  affords 
easy  egress  to  the  hernia.  At  the  femoral  canal,  on  the  contrary,  the 
possible  hernial  opening  is  quite  adequately  protected,  owing  to  the 
close  relationship  existing  in  the  child  between  the  anterior  superior 
iliac  spine,  Poupart's  ligament,  and  the  spine  of  the  pubes.  Conse- 
quently femoral  hernia  in  childhood  is  rare. 

A  more  direct  and  exciting  cause  of  hernia  is  the  pressure  exerted 
bj'-  the  abdominal  muscles  in  crying,  particularly  from  colic,  and  during 
paroxysms  of  whooping-cough. 

Diagnosis  and  Differential  Diagnosis.^-Inguinal  hernia  in  infants 
is  usually  readily  reducible,  and  this  facts  permits  of  making  the  diag- 
nosis positive. 

Strangulated  inguinal  hernia  may  be  confused  with  hydrocele  of 
the  cord,  enlarged  inguinal  glands,  and  undescended  testicle. 

In  hydrocele  the  tumor  is  translucent,  which  may  be  readily  proved 
by  means  of  the  following  hght  test:  A  piece  of  dark,  stiff  paper  is  rolled 
in  tube  form,  so  that  the  orifice  is  3^^  inch  in  diameter.  One  end  of  the 
paper  tube  is  placed  over  the  tumor,  which  is  supported  while  a  lighted 
candle  is  placed  underneath.  The  observer 's  eye  is  now  applied  to  the 
other  end  of  the  tube.  If  the  light  is  not  transmitted  through  the  mass, 
hernia  in  all  probability  is  present. 

Further,  if  strangulated  hernia  has  persisted  for  even  a  few  hours, 
there  will  be  vomiting  and  pronounced  abdominal  distention. 

In  the  condition  known  as  undescended  testicle  the  testicle  is  absent 
from  the  scrotum  and  may  be  demonstrated  in  the  canal  as  a  small, 


756  THE  PRACTICE  OF  PEDIATRICS 

ovoid,  movable  mass.  I  have  known  of  the  wearing  of  a  truss  over  an 
undescended  testicle. 

When  due  to  enlarged  inguinal  glands,  the  tumor  is  placed  to  the 
left  or  right  of  the  canal.  It  is  firm,  hard,  and  fixed,  and  usually  more 
than  one  gland  is  involved.  It  would  seem  that  there  should  be  no 
necessity  for  confusion  in  the  differentiation  of  a  gland  mass. 

Prognosis. — The  prognosis  for  cure  of  uncomplicated  hernia  without 
operative  procedure  is  good.  At  least  98  per  cent,  of  my  cases  are 
cured  in  from  six  months  to  one  year,  through  the  use  of  suitable 
appHances. 

Treatment. — The  treatment  of  inguinal  hernia  in  infants  and 
young  children  is  by  mechanical  appliances  or  by  operation.  In 
infants  under  one  year  of  age  operation  is  rarely  required.  The  most 
satisfactory  means  in  my  hands  for  treating  inguinal  hernia  has  been 
the  Hood  frame  truss,  made  of  hard  rubber.  Measurement  for  the 
truss  is  taken  around  the  hips  on  a  plane  with  the  hernia.  The  truss, 
if  placed  in  hot  water  for  a  few  seconds,  or  warmed  slightly  before  a 
fire,  can  readily  be  bent,  so  as  to  fit  the  patient  comfortably.  When 
the  truss  is  removed  for  the  purpose  of  cleansing,  which  should  be 
done  twice  a  day,  a  helper  should  be  at  hand  to  maintain  support  at 
the  ring,  so  that  there  shall  be  no  descent  of  the  hernia.  One  descent 
may  mean  that  several  weeks'  care  has  been  brought  to  naught.  The 
child  should  wear  the  truss  day  and  night.  The  skin,  where  subject 
to  pressure,  should  be  kept  well  powdered  when  the  truss  is  first  ap- 
plied, and  the  child  is  often  made  more  comfortable  by  placing  ab- 
sorbent cotton  beneath  the  hard-rubber  pad. 

As  the  child  grows  the  truss  will  have  to  be  changed  frequently. 
Its  use  should  be  continued  for  at  least  six  months  after  the  last  descent 
of  the  hernia.  Operation  is  required  when  the  hernia  becomes  strangu- 
lated, and  this  procedure  is  always  to  be  advised  for  older  children  if  a 
cure  is  not  affected  after  two  years'  treatment  by  a  truss.  Many  of  my 
cases  have  entirely  recovered  in  less  than  six  months.  The  use  of  the 
truss,  in  such  instances,  however,  is  continued  with  a  view  to  protecting 
the  parts  and  preventing  a  recurrence  of  the  hernia  under  stress. 

VENTRAL  HERNIA 

This  form  of  hernia  is  of  congenital  origin,  and  is  only  occasionally 
seen  in  infants.  It  may  be  associated  with  umbilical  hernia  or  it  may 
occur  independently.  It  may  be  due  to  a  failure  of  the  recti  to  unite 
in  the  median  line,  or  it  may  be  due  to  weakness  or  imperfect  develop- 
ment of  the  fibers  of  either  muscle.  Muscular  atrophy  following 
poliomyelitis  was  the  cause  in  two  of  my  cases. 

There  is  rarely  any  great  protrusion  of  the  abdominal  contents, 
as  in  the  other  forms  of  hernia.  Usually  a  ventral  hernia  manifests 
itself  in  a  fullness  or  distinctly  localized  elevation  of  the  skin  over  the 
site  of  the  absent  or  weakened  muscle  tissue  in  the  abdominal  walls. 
The  usual  location  is  in  the  hypochondrium.     I  have  seen  from  two 


DIAGNOSIS   IN  BONE    AND   JOINT   DISEASES  757 

to  three  hernias  in  one  subject  in  this  locahty.  In  one  case  the  hernia 
was  in  the  right  lumbar  region.     Not  all  cases  require  treatment. 

Treatment. — The  application  of  a  four-inch  strip  of  zinc  oxid  ad- 
hesive plaster  2  or  3  inches  wide,  placed  flat  on  the  skin  over  the  hernia, 
is  all  that  will  usually  be  required.  The  support  thus  furnished  must 
be  continued  for  several  months.  Operation  may  sometimes  be  neces- 
sary, but  has  not  been  required  in  my  cases. 

Diaphragmatic  Hernia. — These  cases  are  very  unusual.  Only  one 
has  come  under  my  observation.  In  this  case,  as  in  others  reported,  the 
defect  was  located  at  the  left  anterior  border  of  the  diaphragm.  This 
allowed  the  intestines  to  pass  into  the  pulmonary  cavity,  displacing 
the  heart  and  the  lungs.  As  may  be  imagined,  the  physical  chest  signs 
thus  produced  are  most  unusual  and  puzzling. 

DIAGNOSIS  IN  BONE  AND  JOINT  DISEASES 

It  is  not  within  the  province  of  this  book  to  enter  the  domain  of 
orthopedic  surgery.  The  practitioner,  however,  is  the  first  to  see  cases 
of  illness  regardless  of  their  nature,  and  bone  and  joint  diseases  are  no 
exception  to  the  rule.  For  this  reason  these  diseases  will  be  considered 
largely  from  the  standpoint  of  diagnosis.  In  the  examination  for  bone 
and  joint  diseases  in  runabout  and  older  children  the  patient  should 
invariably  be  stripped.  He  should  then  be  encouraged  to  move  about, 
to  run  and  play,  to  sit  down,  to  lie  down,  to  roll  over  on  his  stomach  and 
back  again.  He  may  be  asked  to  pick  up  toys,  to  walk  up  and  down 
stairs,  to  climb  into  a  chair.  By  these  means  limitation  of  motion,  a 
most  valuable  symptom  in  joint  disease,  is  made  apparent. 

Acute  Peri-arthritis. — In  infants  and  young  children  observed  in 
hospital  work  an  infection  of  the  peri-articular  structures  is  not  at  all 
uncommon.  The  symptoms  presented  are  those  of  superficial  swelling, 
and  at  times  redness  and  pain  upon  manipulation.  Fluctuation  will  be 
present  if  the  case  is  at  all  advanced.  In  my  cases  the  shoulder-  and 
elbow-joints  have  been  the  more  frequently  involved.  The  disease 
may  be  due  to  any  of  the  pathogenic  organisms.  In  a  recent  case  an 
examination  of  the  pus  showed  pure  influenza  bacillus  infection.  The 
gonococcus  may  produce  either  a  peri-arthritis  or  an  arthritis.  Eleva- 
tion of  temperature  is  an  inconstant  symptom.  It  may  be  present  or 
absent. 

Arthritis. — In  arthritis  the  symptoms  are  usually  more  urgent. 
The  temperature  is  higher,  102°  to  104°F.,  and  there  is  complete  loss  of 
power  in  the  limb  involved,  associated  with  pain,  swelling,  and  redness. 
As  in  peri-arthritis,  any  one  of  the  pyogenic  organisms  may  be  the  in- 
fecting agent. 

Gonorrheal  Arthritis. — In  gonorrheal  arthritis  the  lesion  is  apt  to 
be  multiple.  I  have  seen  as  many  as  five  joints  involved  in  one  patient. 
The  small  joints  of  the  hands  are  particularly  apt  to  be  involved  in  in- 
fants with  gonorrheal  arthritis.  Arthritis  and  peri-arthritis  are  often 
confused  with  rheumatism.     In  the  non-gonorrheal  cases  the  urgency 


758  THE    PRACTICE    OF    PEDIATRICS 

of  the  constitutional  symptoms  and  the  severe  local  lesion,  with  the 
rapid  development  of  pus,  renders  a  diagnosis  fairly  simple.  In  gon- 
orrheal arthritis  one  may  have  to  look  to  the  age  as  a  point  in  differenti- 
ation. Children  under  eighteen  months  rarely  have  rheumatism,  and 
in  the  very  young,  successive,  severe,  inflammatory  joint  infections 
should  always  arouse  the  suspicion  of  an  infectious  arthritis. 

Joint  Tuberculosis. — While  tuberculosis  may  develop  in  any  bony 
structure,  that  form  with  which  we  are  particularly  concerned  in 
diagnosis  affects  the  hip  and  spine. 

Tuberculosis  of  the  Spine. — Tuberculosis  of  the  spine  may  occur 
in  quite  young  infants.  My  youngest  patient  was  nine  months  of  age. 
While  the  symptoms  vary  somewhat,  depending  upon  the  location  of 
the  inflammation,  one  symptom  is  almost  always  present  early  in  the 
illness — stiffness,  a  tendency  to  hold  the  body  rigid.  The  child  moves 
awkwardly.  If  the  cervical  vertebrse  are  involved,  the  head  will  be 
held  fixed  on  the  shoulders,  often  with  a  bearing  slightly  either  to  the 
right  or  the  left,  resembling  the  attitude  of  torticollis.  If  the  dorsal  or 
lumbar  vertebrae  are  involved,  the  child  holds  the  body  erect  and  all 
movements  are  made  with  care  and  caution.  The  shoulders  are 
thrown  backward,  the  child  assuming  a  military  attitude.  Bending 
the  body  is  difficult.  When  the  child  attempts  to  pick  an  object  from 
the  floor,  the  spine  is  held  rigid,  while  extreme  flexion  takes  place  in  the 
knees  in  order  to  bring  the  hand  to  the  floor.  Pain  reflected  anteriorly 
may  be  present,  not  always  early  in  the  case. 

In  every  motion  the  child  attempts  to  protect  the  sensitive  spine, 
making  all  voluntary  motions  with  precision  and  apparent  forethought. 

Early  in  the  disease  there  is  no  deformity.  The  first  objective  sign 
to  appear  is  a  projection  or  undue  prominence  of  one  or  more  of  the 
spinal  processes.  After  the  development  of  the  angular  bony  deformity 
the  disease  is  unmistakable. 

Tuberculous  Disease  of  the  Hip. — This  is  very  rare  in  infancy. 
The  first  symptom  is  a  slight  limp,  due  to  spasticity  of  the  hip  muscles, 
which  causes  the  child  to  step  short.  The  onset  of  the  disease  is  very 
gradual,  and  the  limping  may  disappear  for  weeks  at  a  time  and  return 
again,  and  again  disappear.  Pain  in  the  anterior  portion  of  the  thigh 
just  above  the  knee  is  an  early  symptom. 

Illustrative  Case. — A  boy  twelve  years  old  who  came  under  my  care  had  a 
periodic  limp  or  short  step  for  six  years;  he  had  been  treated  for  various  conditions, 
particularly  for  rheumatism.  I  referred  him  to  an  orthopedist,  who,  after  several 
weeks  of  observation  assisted  by  an  2;-ray,  pronounced  the  condition  tuberculous. 

A  shortening  of  the  gluteal  fold  and  a  general  flattening  of  the  hip 
with  an  increased  prominence  of  the  trochanter  are  characteristic  of 
hip  disease. 

The  tendency  to  spasticity  of  the  hip  muscles  furnishes  a  most 
valuable  diagnostic  aid.  There  is  a  general  limitation  of  motion  as 
compared  with  that  of  the  sound  side:  abduction,  adduction,  flexion, 
extension,  and  rotation  are  all  retarded.     The  joint  appears  fixed. 


DIAGNOSIS    IN   BONE    AND    JOINT   DISEASES  759 

Tilting  of  the  pelvis,  due  to  the  muscular  spasticity,  consists  in  an  ele- 
vation of  the  patient's  back  from  the  table  when  the  extended  leg  of 
the  affected  side  rests  fully  upon  the  table.  In  more  advanced  cases 
there  is  the  eversion  of  the  foot. 

Outward  rotation  of  the  entire  limb  and  apparent  lengthening,  pain, 
inability  to  walk,  and  abscess  are  the  outcome  in  cases  unsuccessfully 
treated. 


XIX,  SUGGESTIONS  IN  MANAGEMENT 
VACCINATION 

Every  infant  in  fair  health  should  be  vaccinated.  The  vaccination 
should  be  done  as  soon  as  the  child  is  thriving  on  a  rational  diet.  The 
younger  the  child  at  the  time  of  vaccination,  the  less  the  constitutional 
disturbance.  In  well  infants,  vaccination  should  never  be  delayed 
beyond  the  fifth  month. 

The  Site. — The  site  selected  for  the  vaccination  in  boys  is  usually 
on  the  left  arm,  at  about  the  point  of  insertion  of  the  deltoid,  and  in 
girls  on  the  outer  aspect  of  the  calf  of  the  leg.  I  have  found,  however, 
that  it  is  a  matter  of  much  more  convenience  to  the  mother  in  dressing 
and  handling  the  child  if  the  leg  is  selected  in  both  sexes.  The  dressing 
is  more  easily  applied  to  the  wound  and  can  more  readily  be  kept  in 
place  on  the  leg.  Further,  in  the  manipulation  necessary  in  dressing 
and  undressing,  much  less  discomfort  is  occasioned  when  the  sore  is  on 
the  leg. 

The  Method. — Before  scarification  of  the  skin,  the  site  selected  should 
be  well  scrubbed  with  common  soap  and  water,  dried,  and  then  washed 
with  alcohol.  The  area  of  scarification  should  not  be  over  one-quarter 
of  an  inch  in  diameter,  and  should  be  sufficient  to  produce  only  a  light 
flow  of  serum,  A  deep  scarification,  producing  a  free  flow  of  blood, 
is  very  apt  to  be  unsuccessful.  The  best  scarifier  is  an  ordinary  sew- 
ing-needle, which  should  be  sterilized  by  placing  the  point  for  a  few 
seconds  in  an  alcohol  flame.  The  virus  which  is  furnished  in  hermeti- 
cally sealed  capillary  glass  tubes  is  the  safest  to  use.  The  drop  of  virus 
is  to  be  deposited  on  the  abraded  surface  and  rubbed  well  into  the 
wound,  using  the  side  of  the  needle  for  this  purpose.  When  the 
wound  is  thoroughly  dried,  a  protective  dressing  should  be  applied. 
The  safest  and  most  convenient  is  a  sterile  gauze  bandage,  which  is 
wrapped  several  times  around  the  arm  or  leg  and  secured  with  a  safety- 
pin.  On  account  of  the  shape  and  position  of  the  parts,  the  bandage  is 
very  apt  to  become  displaced  downward.  In  order  to  prevent  this,  a 
strip  of  adhesive  plaster  one  inch  wide  and  five  or  six  inches  long  may  be 
placed  over  the  bandage  at  right  angles  to  it ;  the  middle  portion  of  the 
plaster  readily  adheres  to  the  bandage,  and  the  two  ends,  at  least  two 
inches  long,  are  anchored  to  the  skin. 

The  After-treatment. — The  mother  should  be  instructed  to  report 
five  days  after  the  vaccination.  On  the  fifth  day  the  dressing  may 
be  removed,  and  if  the  vaccination  is  successful,  the  characteristic 
pearl-like  vesicle  will  be  present.  If,  on  account  of  accident  or  rubbing 
of  the  parts  by  the  patient,  the  vesicle  is  broken,  the  non-adhering 
gauze  should  be  carefully  cut  away  around  the  sore,  allowing  that  which 

760 


VACCINATION  761 

adheres  to  remain.  Under  no  conditions  should  the  wound  be  opened. 
Again,  a  gauze  dressing  should  be  applied  and  kept  in  position  by  ad- 
hesive strips.  At  the  end  of  the  exudative  stage,  usually  about  five  or 
six  days,  the  dressing  should  again  be  changed,  either  by  the  mother  or 
the  physician,  and  renewed  until  the  crust  falls,  the  third  to  the  fourth 
week  after  the  vaccination. 

If  there  is  no  sign  of  the  vesicle  in  ten  or  twelve  days,  the  vaccina- 
tion, if  primary,  should  be  repeated.  Revaccination  should  be  prac- 
tised at  least  once  in  five  years,  and  at  more  frequent  intervals  during 
epidemics  of  smallpox. 

Complications. — If  vaccination  is  properly  performed,  the  dangers 
attending  it  are  practically  nil.  That  death  and  serious  results  have 
followed  vaccination  is  no  argument  against  its  use,  but  a  grave  reflec- 
tion on  the  manner  in  which,  as  a  rule,  it  is  performed.  The  scarifica- 
tion of  bacteria-laden  skin,  producing  at  the  outset  an  open  wound 
which  is  indifferently  or  not  at  all  protected  from  further  infection,  is 
very  apt  to  produce  complications  of  a  troublesome  and  often  serious 
nature.  Erysipelas,  extensive  cellulitis,  and  sloughing  of  the  parts 
as  the  result  of  careless  vaccination  are  not  infrequently  seen  at  out- 
patient departments  for  children.  In  two  cases  I  have  seen  reinocula- 
tion,  as  the  result  of  scratching  the  sore,  the  virus  being  transferred  in 
one  case  to  the  upper  lip  and  in  the  other  to  the  upper  eyelid. 

Vaccination  Shield. — There  is  not  a  vaccination  shield  on  the  mar- 
ket, with  which  I  am  familiar,  that  is  safe  for  use.  Some  cause  a 
maceration  of  the  wound,  others  allow  a  free  entrance  of  bacteria,  while 
still  others  prevent  a  free  superficial  circulation  of  the  blood  and  in- 
crease the  chance  of  ulceration.  Moreover,  the  shields  are  very  apt 
to  become  displaced,  causing  a  rupture  of  the  vesicle,  with  resulting 
infection. 

Constitutional  Disturbance. — A  certain  degree  of  constitutional 
disturbance  is  present  in  every  case  in  which  the  vaccination  is  suc- 
cessful. After  the  first  month,  however,  the  younger  the  child,  the  less 
the  constitutional  disturbance.  Children  vaccinated  during  the  second 
or  third  month  suffer  practically  no  inconvenience.  There  is  a  rise  in 
temperature — from  lOO'^  to  101°F. — for  a  day  or  two,  and  when  the 
process  is  at  its  height,  perhaps  a  slight  degree  of  restlessness.  Time 
and  again  I  have  seen  children,  vaccinated  at  this  age,  pass  through  the 
various  stages  without  manifesting  the  slightest  discomfort.  In  older 
children  the  severity  of  the  constitutional  symptoms  appears  to  in- 
crease with  the  age.  Thus,  a  child  in  the  second  or  third  year  may 
have  fever,  102°  to  104°F.,  loss  of  appetite,  coated  tongue,  and  moder- 
ate prostration.  Very  active  symptoms  rarely  last  longer  than  three 
days  unless  there  is  considerable  accompanying  cellulitis. 

Local  Applications. — Active  treatment,  except  for  relief  of  the  imme- 
diate constitutional  symptoms,  is  rarely  required.  Even  when  there  is 
an  active  cellulitis  I  have  found  it  advisable  not  to  attempt  local 
applications,  such  as  lotions  or  compresses.  All  ointments  have  a 
tendency  to  dissolve  and  loosen  the  crust,  producing  an  open  wound. 


762  THE    PRACTICE    OF    PEDIATRICS 

When,  on  account  of  suppuration,  the  crust  falls,  leaving  a  deep  ulcer 
formed  by  granulation  tissue,  active  local  treatment  will  be  required. 
Such  ulcers  are  often  seen  in  outpatient  work.  A  wet  dressing  of  a 
saturated  solution  of  boric  acid  has  answered  well  in  these  cases.  If 
the  wet  dressing  cannot  be  kept  properly  applied,  a  10  per  cent,  oint- 
ment of  boric  acid,  applied  twice  a  day,  will  be  found  of  considerable 
service  in  hastening  the  closure  of  the  wound.  The  ointment  should  be 
smeared  freely  on  gauze  or  clean  linen  and  held  in  position  by  a  properly 
applied  bandage.  In  young  children  the  ulcers  are  often  most  ob- 
stinate. In  a  few  instances  I  have  known  them  to  continue  from 
eight  to  ten  weeks.  In  cases  in  which  the  healing  has  been  particularly 
slow,  the  familiar  dressing  of  balsam  of  Peru  (5  per  cent.)  in  castor  oil, 
applied  twice  daily  on  a  pad  of  several  thicknesses  of  gauze  and  covered 
with  oiled  silk,  has  appeared  to  hasten  the  granulation.  Unhealthy 
granulations  may  have  to  be  curetted  before  the  dressing  is  applied. 

DAYS  TO  GO  OUT-OF-DOORS;  INDOOR  AIRING 

Physicians  are  frequently  consulted  as  to  the  age  when,  and  the 
conditions  under  which,  it  is  permissible  to  take  the  baby  out-of-doors. 
To  answer  this,  the  place  in  which  the  child  lives,  the  season  of  the 
year,  and  the  age  and  condition  of  the  patient  must  be  taken  into 
consideration. 

A  child,  regardless  of  the  age,  should  never  be  taken  out  in  inclem- 
ent weather.  If  under  one  year,  he  should  not  go  out  if  the  tempera- 
ture is  below  20°F.  During  the  midday  heat  of  summer  the  baby  is 
better  6&  in  the  largest  and  coolest  room  in  the  house  or  on  a  shady 
veranda.  On  very  windy  days  the  young  infant  should  not  go  out; 
neither  should  he  go  out  when  the  snow  is  melting  in  large  quantities. 
When  going  out,  on  account  of  unfavorable  conditions  of  the  weather,  is 
prevented,  there  should,  however,  be  no  lack  of  fresh  air — the  child 
should  be  given  an  indoor  airing,  dressed  as  for  the  daUy  outing.  All 
the  windows  of  the  nursery  or  some  other  large,  sunny  room  should  be 
opened  on  one  side  of  the  room  only.  The  doors  should  be  closed,  so 
that  currents  of  air  are  avoided.  The  child  should  then  be  placed  in  his 
carriage,  suitably  covered,  and  left  in  the  open  room  all  day,  except  when 
he  is  fed  and  "changed."  Here  he  receives  all  that  is  good  from  out- 
doors and  avoids  much  that  is  objectionable  outside,  in  the  forms  of 
dust  and  moisture. 

This  method  will  be  found  very  useful  in  caring  for  "winter  babies" 
— those  born  during  the  late  fall  or  winter  months.  The  indoor  airing 
may  be  given  for  a  week  or  more,  before  the  infant  is  taken  out.  By 
this  means  the  child  may  be  gradually  accustomed  to  a  change  of  tem- 
perature from  that  of  the  average  living-room  to  that  out-of-doors,  and 
will  not  be  harmed  when  finally  taken  out.  After  an  illness,  further- 
more, indoor  airing  will  afford  an  earlier  means  of  returning  to  the 
daily  outing.  This  indoor  method  of  giving  a  child  fresh  air  will  be 
found  useful  with  very  delicate  children  also,  who,  by  reason  of  their 


INSTRUCTIONS    FOR    THE    SUMMER  763 

condition,  may  be  unable  to  go  out,  during  the  winter  months,  for 
several  weeks  at  a  time.  Few  days  during  the  winter  are  too  cold  or 
too  stormy  for  the  indoor  airing. 

INSTRUCTIONS  FOR  THE  SUMMER 

In  addition  to  advising  parents  as  to  a  selection  of  a  summer  resort 
for  the  family,  I  advise  the  mother  as  to  the  particular  care  of  the  child 
during  the  summer,  whether  he  is  to  remain  in  town  or  go  to  the  coun- 
try. During  the  months  preceding  the  heated  term  every  mother 
whose  infant  is  under  my  care  is  made  aware  of  the  dangers  of  the 
next  few  months,  and  means  are  suggested,  and  written  directions 
are  given,  as  to  how  to  pass  through  the  summer  with  the  greatest 
security. 

Selection  of  Milk. — The  mother  is  told  what  market  milks  are  the 
best.  She  is  told  that  the  milk  must  be  kept  on  ice,  with  ice  surround- 
ing the  bottle,  from  the  time  of  its  delivery  until  it  is  given  to  the 
child,  except,  of  course,  during  the  time  spent  in  its  special  preparation. 

Reduction  of  Food  Strength. — During  the  hot  months  in  the  city 
the  child 's  digestive  capacity  is  not  equal  to  that  of  the  colder  months. 
Children  who  remain  in  the  city  are  given  weaker  milk  mixtures,  in 
which  the  fat  and  proteid  are  reduced  from  15  to  25  per  cent.,  the  sugar 
remaining  the  same.  The  infant  may  not  gain  very  much  in  weight, 
but  on  a  reduced  diet  he  is  much  more  apt  to  pass  through  the  summer 
without  intestinal  disorders,  and  there  is  abundant  opportunity  for 
him  to  gain  later  on. 

Clothing. — Mothers  are  instructed  as  to  the  amount  of  clothing 
required.  They  are  told  that  a  napkin,  a  muslin  slip,  a  loose-mesh 
knitted  band,  are  all  that  are  required  on  very  hot  days. 

Water  to  Drink. — ^Bathing. — They  are  instructed  to  give  the  infant 
frequent  drinks  of  boiled  water  between  feedings,  and  if  he  suffers 
much  from  the  heat,  as  shown  by  prickly  heat  and  restlessness,  to 
give  him  two  or  three  spongings  daily  with  a  cool  solution  of  bicar- 
bonate of  soda,  one  teaspoonful  to  a  pint  of  water. 

Withdrawal  of  Milk. — It  is  made  very  plain  that  vomiting  or  a 
green,  undigested  stool  is  a  danger-signal  which  always  means  that  the 
milk  must  be  withheld  for  twenty-four  hours  or  longer  whether  the 
child  is  nursed  or  bottle-fed,  and  that  either  barley-water  or  one  of  the 
other  carbohydrate  gruels  (p.  70)  must  be  substituted  until  such  time 
as  the  stools  improve  or  the  vomiting  ceases.  This  is  one  of  the  most 
important  life-saving  measures  the  physician  can  teach  the  mother. 
An  immense  majority  of  the  intestinal  diseases  of  summer,  which  de- 
troy  thousands  of  lives  yearly,  have  their  origin  in  a  neglected  acute 
indigestion  and  diarrhea,  which  if  properly  managed  means  a  slight 
illness  of  but  a  day  or  two.  It  is  further  impressed  upon  the  mothers 
that  upon  resuming  milk  diet  it  must  be  given  at  first  greatly  reduced 
in  strength,  and  then  gradually  increased  until  food  of  the  previous 
strength  is  given.     Beginning  with  one-half  ounce  of  skimmed  milk 


764  THE  PRACTICE  OF  PEDIATRICS 

in  each  feeding,  by  watching  effects  upon  the  temperature  and  the 
stools,  an  increase  of  perhaps  one-half  ounce  may  be  made  each  day. 

How  to  Obtain  Safe  Milk. — I  have  experienced  not  a  little  trouble 
in  the  past  in  securing  safe  milk  for  infants  who  were  removed  at  a 
considerable  distance  from  the  depots  of  the  better  class  of  dairies  that 
supply  certified  milk.  The  average  farmer  is  notoriously  careless  in 
the  handhng  of  milk,  and  in  the  country  districts,  where  the  milk- 
supply  should  be  the  best,  it  is  often  as  bad  as  can  well  be  imagined. 
In  remote  country  districts,  where  the  milk  is  furnished  by  the  farmer, 
a  special  arrangement  is  made,  by  which  he  agrees  that  the  cow's 
belly,  udders,  and  teats  shall  be  wiped  off  with  a  damp  cloth  before 
milking;  that  the  milker's  hands  shall  be  washed  before  milking;  that 
the  few  jets  of  the  foremilk  shall  be  thrown  away;  and  that  as  soon  as 
the  milk  is  drawn  it  shall  be  strained  through  sterilized  absorbent 
cotton  into  a  quart  milk  bottle,  suitably  corked,  and  placed  in  a  pail  of 
cracked  ice.  The  cracked  ice  and  the  absorbent  cotton  are,  of  course, 
furnished  by  the  consumer.  For  the  extra  trouble  the  farmer  receives 
from  15.  to  20  cents  a  quart  for  the  milk.  At  one  resort  three  babies 
were  supplied  in  this  way,  by  one  small  producer,  with  a  comparatively 
safe  milk.  The  improved  milk-pail  with  a  narrow  opening  insures  a 
much  cleaner  milk,  as  it  offers  much  less  opportunity  for  droppings  to 
fall  into  it  during  the  milking  than  does  the  old-style  pail. 

For  those  who  have  country  homes  and  who  can  control  their  milk- 
supply  the  above  precautions  may  be  carried  out  to  the  letter.  By 
such  careful  control  of  the  home  product,  and  by  the  use  of  milk  from 
those  dairies  only  which  observe  the  above  precautions,  the  acute 
digestive  disorders  of  summer  among  my  patients  are  rendered  very 
unusual.  These  precautions,  with  the  knowledge  of  the  mother  or 
nurse  as  to  what  to  do  at  the  first  sign  of  a  digestive  disorder,  will  reduce 
the  number  of  the  so-called  summer  diarrhea  cases  to  a  very  insignifi- 
cant figure. 

Among  outpatients  in  large  cities  who  have  to  use  other  milk  and 

milk  less  clean,  summer  diarrhea  must  prevail.     Among  these,  however, 

the  death-rate  may  be  remarkably  reduced  through  the  education  of 

the  mothers.     At  the  outpatient  department  at  the  Babies'  Hospital 

dispensary,  where  there  is  a  clientele  of  fairly  intelligent  mothers  who 

have  been  coming  to  us  for  years,  there  is  a  very  low  death-rate  from 

summer  diarrhea.     By  pamphlets  of  instructions  as  given  below,  and 

by  showing  these  mothers  that  we  have  a  personal  interest  in  their 

children,  we  gain  their  confidence.     They  believe  what  we  tell  them, 

and,  as  a  result,  we  repeatedly  have  children  brought  to  us  well  along 

the  road  to  recovery. 

For  example,  a  child  had  developed  diarrhea;  he  had  been  given  a  dose  of  castor 
oil,  his  milk  was  stopped  and  barley-water  or  rice-water  given. 

The  mothers  are  further  told  that  it  is  never  a  good  thing  for  a 
baby  to  have  diarrhea;  that  a  diarrhea  is  never  without  dangers;  that 
an  infant  who  has  frequent  attacks  of  indigestion  during  the  cooler 
months  is  very  sure  to  develop  diarrhea  during  the  hot  months,  and  that 


INSTRUCTIONS    FOR   THE    SUMMER  765 

the  safest  means  of  keeping  a  baby  well  in  the  summer  is  to  keep  him 
well  all  the  year  round. 

Rules  for  the  Care  of  Dispensary  Infants  and  Young  Chil- 
dren During  the  Summer 

1.  Clothing. — During  the  very  hot  days  the  baby  should  wear  a 
napkin,  a  thin  gauze  shirt,  and  a  thin  muslin  slip.  An  abdominal  binder 
made  of  thin  material,  and  loosely  applied,  may  be  worn  until  the 
child  is  six  months  of  age.     After  this  age  the  binder  is  not  necessary. 

2.  Bathing. — Every  child  should  have  one  tub-bath  daily.  On 
very  warm  days  from  two  to  four  ten-minute  spongings  with  cool  soda 
water  (one  teaspoonful  of  bicarbonate  of  soda  to  a  pint  of  water)  will 
greatly  add  to  the  child 's  comfort. 

3.  Fresh  Air. — Fresh  air  is  of  vital  importance.  Leave  the  windows 
open.  Keep  the  child  in  the  open  air  when  possible.  Avoid  the  sun. 
Select  the  shady  side  of  the  street  and  the  shade  in  the  parks. 

4.  Sleep. — Sleep  is  very  necessary  for  growing  children.  A  noon- 
day nap  of  at  least  two  hours  should  be  insisted  upon  until  the  child  is 
four  years  of  age. 

5.  Soiled  Napkins. — -Soiled  napkins  should  be  placed  in  some 
covered  receptacle  containing  water,  and  washed  at  the  earliest 
opportunity. 

6.  Drinking-water. — Boil  one  quart  of  water  every  morning.  Put 
it  into  a  clean  bottle.  Keep  the  bottle  in  a  cool  place.  Give  the  water 
between  the  feedings — as  much  as  the  child  will  take. 

7.  Breast-feeding. — The  mother  should  wash  the  nipple  with  plain 
cold  water  before  each  nursing.  She  should  be  very  careful  as  to  her 
diet  and  habits  of  life.  Her  bowels  should  move  once  a  day.  Con- 
stipation in  the  mother  produces  illness  in  the  child.  She  should  have 
three  plain,  well-cooked  meals  daily,  consisting  largely  of  milk,  meat, 
vegetables,  and  cereals.  Beer  and  tea  are  often  harmful.  A  large 
quantity,  a  couple  of  pints  or  more  daily  of  either  is  positively 
objectionable. 

From  birth  to  the  third  month:  The  baby  should  be  nursed  at  three- 
hour  intervals  during  the  day.  Seven  nursings  in  twenty-four  hours, 
with  only  one  nursing  between  10.30  p.  m.  and  6  a.  m. 

Third  to  sixth  month :  The  nursings  should  be  at  three-hour  intervals 
during  the  day;  6  nursings  in  twenty-four  hours ;  no  night  feeding. 

Sixth  to  twelfth  month :  The  child  now  takes  a  larger  quantity  at  each 
feeding.  He  should  be  nursed  at  four-hour  intervals;  5  nursings  in 
twenty-four  hours. 

8.  Bottle-feeding. — The  bottle  should  be  thoroughly  cleansed  with 
borax  and  hot  water  (one  teaspoonful  of  borax  to  a  pint  of  water)  and 
boiled  before  using.  The  nipple  should  be  turned  inside  out,  and 
scrubbed  with  a  brush,  using  hot  borax  water.  The  brush  should  be 
used  for  no  other  purpose.  There  should  be  three  or  four  sets  of  bottles 
and  nipples.     The  bottles  and  nipples  should  rest  in  plain  boiled  water 


766  THE  PRACTICE  OF  PEDIATRICS 

until  wanted.  Never  use  grocery  milk.  Use  only  bottled  milk  which 
is  delivered  every  morning.  The  milk  should  be  boiled  for  five  minutes 
immediately  after  receiving.  The  feeding  hours  are  the  same  as  in 
breast-feeding.  Children  of  the  same  age  vary  greatly  as  to  the 
strength  and  amount  of  food  required.  Food,  when  prepared,  should 
be  poured  into  a  covered  glass  fruit-jar  and  kept  on  the  ice.  For  the 
average  baby  the  following  mixtures  will  be  found  useful: 

For  a  child  under  three  months  of  age:  Nine  ounces  of  milk,  27  ounces 
of  boiled  water,  4  teaspoonfuls  of  granulated  sugar.  Feed  from  3  to  4 
ounces  at  three-hour  intervals — 7  feedings  in  twenty-four  hours. 

Third  to  sixth  month:  Eighteen  ounces  of  milk,  30  ounces  of  barley- 
water,  6  teaspoonfuls  of  sugar.  Feed  5  to  6  ounces  at  three-hour 
intervals — '6  feedings  in  twenty-four  hours.     No  night-feeding. 

Barley-water  is  prepared  by  boihng  a  tablespoonful  of  Robinson's 
barley  flour  or  Cereo  Co.'s  barley  flour  in  one  pint  of  water  for  twenty 
minutes;  strain  and  add  water  to  make  one  pint. 

Sixth  to  ninth  month:  Twenty-four  ounces  of  milk,  24  ounces  of 
barley-water,  6  teaspoonfuls  of  granulated  sugar.  Feed  7  to  8  ounces 
at  four-hour  intervals — 5  feedings  in  twenty-four  hours. 

Ninth  to  twelfth  month:  Thirty-eight  ounces  of  milk,  12  ounces  of 
barley-water,  6  teaspoonfuls  of  granulated  sugar.  Feed  7  to  9  ounces 
at  four-hour  intervals — 5  feedings  in  twenty-four  hours. 

9.  Condensed  Milk. — When  the  mother  cannot  afford  to  buy  bottled 
milk,  when  she  has  no  ice-chest  or  cannot  afford  to  buy  ice,  she  should 
not  attempt  cow's  milk  feeding.  Canned  condensed  milk  should  be 
used  as  a  substitute  during  the  hot  months  only.  The  can,  when 
opened,  should  be  kept  in  the  coolest  place  in  the  apartment,  care- 
fully wrapped  in  clean  white  paper.  The  feeding  hours  are  the  same 
as  for  fresh  cow's  milk. 

Under  three  months  of  age:  One-half  to  2  teaspoonfuls  condensed 
milk;  barley-water  No.  1  (see  formulary,  p.  70),  2  to  4  ounces. 

Third  to  sixth  month:  Condensed  milk,  2  to  3  teaspoonfuls;  barley- 
water,  4  to  6  ounces. 

Sixth  to  ninth  month:  Condensed  milk,  3  to  4  teaspoonfuls;  barley- 
water,  6  to  8  ounces. 

Ninth  to  twelfth  month:  Condensed  milk,  4  to  5  teaspoonfuls ;  barley- 
water,  8  to  9  ounces. 

10.  Feeding  After  One  Year  of  Age. — All  children  should  be  weaned 
at  the  age  of  twelve  months  unless  other  orders  are  given  by  a  physi- 
cian. The  bottle-fed,  also,  at  this  age  require  more  than  milk  and 
cereal  water.  During  the  second  year  children  are  almost  invariably 
badly  fed. 

Four  meals  a  day  should  be  given  at  the  same  hours  every  day. 
The  mother  will  select  suitable  meals  from  the  following  articles:  soft- 
boiled  egg;  scraped  rare  beef;  strained  broth  of  beef,  mutton,  or 
chicken  with  stale  bread  broken  into  it;  toast  and  butter;  stale  bread 
and  butter;  toast  and  milk;  stale  bread  and  milk;  oatmeal  (cooked  three 
hours)  and  milk;  hominy  (cooked  three  hours)  and  milk;  cornmeal 


THE    EXERCISE    PEN 


767 


(cooked  two  hours)  and  milk;  farina  (cooked  one  hour)  and  milk.     The 
milk  used  must  be  boiled  during  the  hot  weather. 

11.  Summer  Diarrhea. — When  the  baby  has  loose,  green  passages 
he  is  sick  and  needs  medical  attention.  The  disease  is  frequently  mild 
at  the  beginning.  There  may  be  no  fever  and  the  child  may  show  no 
signs  of  illness  other  than  the  diarrhea.  Such  a  baby  oftentimes,  with 
milk-feeding  continued,  becomes  dangerously,  if  not  fatally,  ill  in  a  very 
few  hours.  The  simplest  cases  of  vomiting  and  diarrhea  during  the 
summer  must  never  be  neglected.  A  baby  sick  in  this  way  should  be 
given  two  teaspoonfuls  of  castor  oil.  Stop  the  milk  at  once.  Give 
only  barley-water  or  rice-water  until  the  child  can  be  taken  to  the  fam- 
ily physician  or  to  a  dispensary.  With  slight  variations  the  above 
rules  may  be  made  to  apply  to  many  outside  of  the  dispensary  class. 


THE  EXERCISE  PEN 

In  another  chapter,  in  speaking  of  "colds,"  and  how  children  are 
exposed  to  the  influences  which  may  bring  about  what  is  known  as  a 


Fig.  112. — The  exercise  pen. 

"cold,"  the  custom  of  allowing  a  child  to  sit  on  the  floor  and  play  at 
all  seasons  of  the  year  is  referred  to  as  a  most  frequent  means  of 
exposure.  There  is  always  a  current  of  air  near  the  floor,  as  one 
readily  discovers  by  resting  his  hand  on  the  floor  on  a  cold  winter  day; 
further,  the  floor  of  the  average  house  is  naturally  the  most  unclean 
part  of  the  dwelling.  Here  dust  gathers  and  dirt  from  the  street 
collects  as  it  is  brought  in  on  the  feet  of  older  members  of  the  family. 
On  this  necessarily  unclean  floor  the  young  child  is  permitted  to  spend 


768  THE    PRACTICE    OF    PEDIATRICS 

a  considerable  portion  of  his  waking  hours.  It  can  readily  be  seen 
that  countless  numbers  of  bacteria  may  be  transferred,  through  the 
medium  of  the  hands,  from  the  floor  to  the  child 's  mouth.  Rugs  and 
pillows,  which  are  sometimes  used,  while  cleaner  than  the  floor,  are  of 
little  assistance  in  preventing  drafts. 

Exercise  is  very  necessary  for  the  child's  proper  growth  and  de- 
velopment. He  must  have  an  opportunity  and  place  in  which  to  creep, 
walk  and  run.  In  order  that  he  may  have  these  advantages  and  not 
be  subjected  to  unfavorable  influences,  I  have  found  the  exercise  pen 
(Fig.  112)  of  the  greatest  service.  After  being  bathed,  dressed,  and  fed 
the  child  is  placed  in  the  pen,  on  a  rug  or  quilt.  Toys  are  given  him 
and  the  door  is  closed.  He  cannot  come  in  contact  with  the  stove,  he 
cannot  roll  downstairs,  and  he  is  in  no  danger  from  the  rough  play  of 
older  children.  He  is  given  an  opportunity  for  active  exercise  without 
a  possible  chance  of  injury. 

The  pen  can  be  made  of  any  size,  but  the  usual  size  is  4  feet  square. 
It  can  be  made  of  any  light-weight  wood,  pine  generally  being  used. 
The  legs  of  the  pen  should  be  at  least  12  inches  long,  bringing  it  well  off 
the  floor.  The  pen  is  so  constructed  that  it  may  readily  be  taken  apart 
and  put  together  again,  iron  tenon  hooks  and  iron  mortices  being  used 
to  hold  the  parts  together.  The  floor  may  be  made  of  any  thin  material. 
One-half  inch  pine  boards  nailed  together,  or  papier-mache  supported 
by  narrow  strips  of  board,  may  be  used.  The  floor  is  supported  by 
strips  of  board  about  one-half  by  two  inches,  which  are  fastened  to  the 
inner  sides  of  the  end-pieces.  The  pen  is  best  placed  in  the  corner  of 
the  nursery  or  the  living  room.  Its  size  may  be  determined  entirely 
by  the  size  of  the  room.  During  warm  weather  in  the  country  the  pen 
may  often  be  used  out-of-doors. 

SUMMER  RESORTS 

Where  to  take  a  baby  for  the  hot  months  of  the  year  is  a  vexed 
question  which  is  raised  in  many  city  households  every  year,  and  it 
is  one  concerning  which  the  physician  is  frequently  called  upon  for 
advice.  Several  years  of  observation  of  a  great  many  New  York  city 
children  who  have  spent  the  summer  out  of  town  have  led  me  to  the 
following  conclusions: 

First,  the  most  desirable  summer  outing  is  to  spend  the  first  half  of 
the  season  at  the  seashore,  the  remainder  inland,  preferably  in  the 
mountains. 

Second,  the  next  place  in  order  of  desirability  is  inland,  preferably 
the  mountains,  for  the  entire  summer. 

Third,  the  least  desirable  is  the  seashore  for  the  entire  summer. 

It  is  not  to  be  understood  that  many  children  will  not  do  well  if 
kept  at  the  seashore  throughout  the  hot  months.  Some,  indeed,  im- 
prove most  satisfactorily,  but  among  my  own  patients  I  have  repeat- 
edly been  impressed  with  the  disadvantages  of  a  too  prolonged  stay  at 
the  seashore.     If  kept  there  during  August,  infants  are  apt  to  show 


FOKEIGN   BODIES    SWALLOWED  769 

signs  of  lassitude,  and  while  not  ill,  they  do  not  return  to  the  city  in  the 
autumn  with  the  vigor,  appetite,  and  general  robustness  which  charac- 
terize those  from  the  hills  and  mountains.  It  must  be  remembered 
that  only  New  York  city  children  are  referred  to .  Children  whose  home 
is  a  seaport  thrive  best  when  given  the  benefit  of  a  complete  change  to 
the  dry,  invigorating  air  inland.  Children  with  catarrhal  tendencies, 
bronchitis,  or  adenoids,  before  or  following  operation,  and  children  who 
have  had  attacks  of  rheumatism  or  who  show  rheumatic  tendencies, 
should  not  go  to  the  seashore,  wherever  their  residence.  For  an  inland 
resort,  the  mountains,  by  which  we  understand  an  elevation  of  1500  to 
2000  feet,  are  not  always  necessary.  The  place  selected,  however, 
should  be  at  an  elevation  at  of  least  600  feet.  For  cases  of  chronic 
bronchitis  and  rheumatism  a  soil  of  sand  or  gravel  is  best,  and  the 
sleeping-room  of  the  child  should  always  be  above  the  ground  floor. 
Other  points  to  be  considered  in  connection  with  the  summer  outing 
are  the  kitchen  facilities,  which  must  be  ample.  Often  the  larger  hotels 
refuse  the  right  of  way  to  the  kitchen.     I  find  that  in  this  respect  much 


Fig.  113. — Small  watch  in  the  esophagus. 

more  liberty  is  given  in  the  smaller  hotels  and  boarding-houses.  The 
proper  preparation  of  the  child's  food  in  the  cramped  quarters  of  sleep- 
ing-rooms is  not  impossible,  but  it  is  often  difficult  and  always  objec- 
tionable; therefore,  if  a  cottage  is  available,  it  will  be  greatly  to  the  child's 
advantage.  Before  selecting  a  home  for  the  summer,  the  drainage  and 
the  source  and  quality  of  the  milk-supply  should  receive  the  most  care- 
ful attention.  Country  well-water  or  spring- water  should  invariably 
be  boiled  before  using. 

FOREIGN  BODIES  SWALLOWED 

Every  practitioner  who  has  to  do  with  children  has  had  occasion  to 
soothe  alarmed  parents  because  of  unusual  substances  swallowed  by 
the  child.     As  a  rule,  the  foreign  bodies  pass  readily  into  the  stomach, 
and  in  due  course  of  time  pass  through  the  natural  channels. 
49 


770  THE    PRACTICE    OF    PEDIATRICS 

Illustrative  Cases. — The  father  of  an  eighteen-months-old  patient  lost  a  diamond 
four-leaf  clover  tie-pin,  and  the  whereabouts  of  the  pin  was  not  known  until  the 
child  passed  it  by  the  bowel. 

The  patient  of  a  colleague  passed  an  open  safety-pin. 

The  accompanying  cut  (Fig.  113)  demonstrates  the  possible  dangers  of  swallow- 
ing foreign  objects.  A  small  watch  disappeared  from  the  neck  of  a  girl  four  years 
of  age.  It  was  assumed  that  it  was  swallowed,  and  the  discharges  were  examined 
daily.  The  child  took  the  usual  diet  without  inconvenience,  and  it  was  assumed 
that  the  watch  had  passed  into  the  stomach.  After  five  days  it  was  decided  to 
locate  the  watch  or  at  least  determine  if  it  was  in  the  child's  digestive  tract.  An 
x-ray  examination  located  the  object  as  shown.  A  surprising  feature  in  this  case 
was  the  passage  of  the  food  alongside  the  watch.  _  Without  the  x-ray  the  case  would 
probably  have  been  fatal,  through  the  formation  of  a  perforating  ulcer  of  the 
esophagus.  The  patient  was  placed  on  her  back  with  the  head  over  the  side  of  a 
table,  to  put  the  mouth  and  esophagus  on  a  plane.  By  means  of  a  "penny- 
catcher"  Dr.  Robert  Abbe,  with  some  difficulty,  succeeded  in  removing  the 
watch. 

It  is  surprising  what  large  and  apparently  dangerous  objects  will 
pass  through  the  entire  gastro-intestinal  tract  without  harm.  The 
danger  lies  in  the  object  becoming  fastened  in  some  portion  of  the  intes- 
tine and  thereby  producing  ulceration  and  perforation. 

Active  laxatives  should  not  be  employed  in  treating  children  who 
have  swallowed  foreign  substances.  Milk,  bread-stuffs,  and  cereal 
foods  that  will  make  a  large  fecal  mass  should  be  given  with  the  hope  of 
carrying  along  the  object.  I  have  seen  a  small  lead-pencil  delayed  for 
two  weeks  and  passed  without  harm. 

The  a;-ray  should  be  used,  repeatedly  if  necessary,  in  all  cases  in 
which  there  is  a  delay  in  the  passage  of  swallowed  foreign  objects. 


XX,  THERAPEUTIC  MEASURES 
THERAPEUTICS  IN  CHILDREN 

It  has  been  my  object,  in  this  work,  to  present  as  clear  and  detailed 
a  description  of  the  management  of  the  illnesses  of  inf ancj^  and  child- 
hood as  space  would  permit,  with  a  view  to  a  better  understanding  of 
pediatric  therapeutics. 

If  I  were  asked  what  I  considered  an  important  requisite  for  the 
successful  practice  of  pediatrics,  I  would  answer:  The  education  of  the 
mother.  It  is  impossible  to  do  even  fairly  good  work  in  treating  dis- 
eases of  children  without  proper  home  cooperation.  A  direction  is 
never  followed  out  as  well  as  when  the  reason  for  it  is  properly  under- 
stood. 

Many  of  our  beneficial  results  are  due  to  the  therapeutic  influences 
of  remedies  outside  of  the  realm  of  drugs.  Thus,  diet,  fresh  air,  cold, 
heat,  massage,  electricity,  climate — all  are  important  therapeutic 
agents  in  the  diseases  of  children.  Successful  therapy  applied  to  chil- 
dren involves  an  understanding  and  a  knowledge  of  detail  greater,  per- 
haps, than  in  any  other  line  of  medical  work.  It  not  infrequently  is  an 
absence  of  such  knowledge  on  the  part  of  medical  men  which  explains 
a  great  deal  of  the  therapeutic  doubt  existing  at  the  present  time. 
Therapeutic  nihilism,  as  far  as  pediatrics  is  concerned,  means  ignor- 
ance and  incompetency.  The  time  when  the  physician  can  make  a 
diagnosis  and  cease  from  interest  in  the  treatment  of  the  case  is  past. 
One  of  two  things  happens  in  the  absence  of  interest  or  ability  on  the 
part  of  the  physician.  The  faith  of  humanity  in  curative  agents  is 
remarkable,  and  when  the  desired  end  is  not  reached  by  the  first  phy- 
sician, some  other  physician  is  called;  and  when  he  fails,  the  next 
resort  usually  is  the  charlatan  and  the  proprietary  and  patent 
medicines. 

The  prosperity  of  the  irregular  schools  of  various  cults  and  ''sciences" 
supposedly  healing  in  character,  and  the  consumption  by  the  people  of 
millions  of  dollars'  worth  of  useless  proprietary  and  patent  drugs,  are 
to  be  attributed  in  a  large  degree  to  an  indifferent  application  of  ther- 
apeutic measures  on  the  part  of  otherwise  well-qualified  medical  men. 
A  few  great  teachers  of  medicine,  by  precept  and  example,  have  done 
an  incalculable  amount  of  harm  in  their  attitude  toward  therapeutics. 
Because  they  were,  or  are,  unable  successfully  to  treat  disease,  they 
assume  that  it  cannot  be  done.  Thus,  therapeutic  doubt,  using  the 
term  therapeutics  in  the  broad  sense,  has  been  in  the  past  boasted  of  by 
men  considered  clever.  Text-books  on  pediatrics  are  not  without  fault 
in  encouraging  careless  practice,  with  necessarily  an  absence  of  favor- 
able results,  especially  when  they  state  that  "treatment  is  along  sup- 

771 


772  THE    PRACTICE    OF    PEDIATRICS 

portive  lines."  What  constitutes  "supportive  lines"  in  a  given  case? 
How  is  the  practitioner  to  know  the  author's  mind?  Or,  again,  per- 
haps it  is  stated  that  "free  stimulation"  is  necessary.  Stimulation 
how,  when,  why,  and  by  what  means  is  what  must  be  known,  in  order 
to  achieve  satisfactory  results.  "Treatment  according  to  the  indica- 
tions of  the  case"  does  not  help  a  puzzled  physician  to  any  great  extent. 
"Treatment  along  the  same  lines  as  in  adults"  adds  no  illumination 
when  a  desperately  sick  child  is  the  patient,  and  moreover  is  faulty 
teaching,  for  the,  reason  that  the  treatment  in  such  instances  should 
never  be  the  same  as  in  adults.  An  infant  or  young  child  should  never 
be  treated  the  same  as  an  adult,  either  by  drugs  or  other  measures,  un- 
less we  wish  more  thoroughly  to  convince  ourselves  of  the  uselessness 
of  therapeutic  measures. 

In  order  to  practise  therapeutics  successfully  in  children  the  meth- 
ods of  the  physician  must  be  flexible  and  adaptable.  Children  vary 
greatly  in  their  physical  and  mental  equipment  much  more  than  do 
adults.  The  practice  of  pediatrics  is  necessarily  difficult,  for  every 
case  has  to  be  studied  from  its  own  standpoint.  The  physician  who 
invariably  treats  all  his  cases  alike  will  never  do  the  highest  class  of 
work  with  children.  The  man,  for  example,  who  feeds  all  his  difficult 
feeding  cases  after  one  rule  or  pattern  will  be  sure  to  have  some  other 
practitioner  get  his  failures,  which  will  not  be  few.  A  source  of  dis- 
appointment to  physicians,  particularly  in  the  treatment  of  young 
infants  and  children,  is  in  the  disorders  of  nutrition.  A  trem.endous 
amount  of  patience  is  required  in  dealing  with  such  cases,  and  the  ab- 
sence of  prompt  results  is  one  of  the  difficult  features  he  has  to  contend 
with  in  his  relations  with  the  family.  There  is,  further,  a  distinction 
to  be  made  as  to  what  constitutes  good  results.  If  the  infant  develops 
into  a  strong  child,  we  may  chronicle  our  results  as  satisfactory  even 
though  a  year  was  required  before  the  condition  of  the  patient  was 
satisfactory.  To  cause  a  malnutrition  baby  weighing  only  eight 
pounds  at  six  months,  with  marked  milk  incapacity,  to  show  rapid 
growth  by  any  method  of  artificial  feeding  is  unusual,  and  our  results 
are  good  if  he  gains  but  little  during  the  first  few  weeks.  Chronic 
colitis,  tardy  malnutrition,  or  nephritis  may  require  months  and  years 
for  correcting  and  yet  furnish  satisfactory  results. 

In  therapeutics  in  infants  and  children,  particularly  as  regards  the 
use  of  drugs,  two  points  are  to  be  kept  in  mind — the  benefit  hoped  for 
and  the  possible  harm  that  may  result.  A  great  deal  of  judgment  must 
be  used  in  the  selection  of  remedies  and  the  means  of  using  them,  lest 
our  best  intentions  result  disadvantageously  to  the  patient.  Thus,  in 
bronchitis  and  in  bronchopneumonia  the  ammonium  salts  are  often 
given  in  combination  with  heavy  syrups,  such  as  tolu  and  wild  cherry, 
both  possessing  little  or  no  value  as  expectorants,  but  having  the  prop- 
erty of  interfering  seriously  with  the  patient's  digestion.  Doubtless 
alcohol  used  indiscriminately  is,  on  the  whole,  productive  of  more  harm 
than  benefit,  largely  through  disturbing  the  digestion.  Digitalis,  the 
salicylates,  and  the  potassium  and  sodium  salts  are  all  to  be  used  with 


THE    THERAPEUTIC   VALUE    OF    CLIMATE  773 

judgment  as  to  method  and  time  of  administration  or  they  will  do  more 
harm  than  good.  A  point  never  to  be  lost  sight  of  in  the  treatment  of 
diseases  of  children  is  the  desirability  of  keeping  the  gastro-enteric 
tract  in  the  best  possible  condition.  In  children  there  are  other  factors 
also  that  bear  upon  the  case  that  tend  toward  good  or  evil.  The  most 
careful  diet,  and  the  best  selected  medication  are  of  little  value  if  the 
patient  is  overclad,  kept  in  a  superheated  room  with  anxious,  often- 
times nervously  exhausted  persons  in  constant  attendance,  with  the 
disturbance  to  the  patient  which  such  attendance  entails.  However, 
it  must  be  remembered  that  absence  of  proper  detail  and  good  judg- 
ment with  resulting  failures  is  no  argument  against  the  value  of  thera- 
peutic measures,  although  it  often  furnishes  the  evidence  upon  which 
the  argument  is  based.  Much  may  be  accomplished,  by  means  of 
prophylaxis,  in  lowering  the  mortality  in  children  under  five  years  of  age. 
In  this  the  educated  mother's  aid  is  invaluable.  She  will  lay  aside  prej  u- 
dices  and  unfavorable  family  influences,  when  a  physician's  direction 
appeals  to  her  reason.  Marasmus,  malnutrition,  and  the  intestinal 
diseases  of  summer,  which  directly  or  indirectly  are  the  cause  of 
thousands  of  deaths  yearly,  are  to  a  large  degree  preventable  if  the 
right  step  is  taken  at  the  right  time,  through  the  early  appreciation  of 
danger-signals  on  the  part  of  both  the  physician  and  the  mother. 

THE  THERAPEUTIC  VALUE  OF  CLIMATE 

That  climate  is  a  valuable  therapeutic  measure  in  the  treatment  of 
diseases  in  children  is  a  well-recognized  fact.  To  my  mind  an  impor- 
tant advantage  of  a  change  of  climate  is  that  it  means  more  air  and  better 
air.  When  patients  go  to  a  resort  for  climatic  purposes  it  is  usually  at 
no  inconsiderable  expense,  and  they  are  therefore  pretty  likely  to  avail 
themselves  of  advantages.  The  same  amount  of  air  oftentimes  could 
be  furnished  at  home  if  the  family  cooperation  always  could  be  secured. 
By  the  use  of  the  window-board,  the  roof-garden,  and  the  indoor  airing 
we  can  to  a  considerable  degree  make  a  climate  of  our  own.  Neverthe- 
less, in  the  majority  of  families  the  open-air  treatment  cannot  be  carried 
out  successfully;  therefore,  the  best  interests  of  the  patients  are  secured 
when  they  are  sent  away  from  home.  There  are  conditions  also  in 
which  such  means  as  those  just  mentioned  do  not  apply  even  if  they  are 
carried  out.  We  can  give  children  warm  air,  and  regulate  the  tempera- 
ture of  the  air  in  the  winter;  but  if  they  live  in  any  of  our  coast  towns  or 
villages,  we  cannot  give  them  cool,  dry  air  in  summer.  Children  who 
can  be  removed  from  a  large  city  to  the  country,  inland,  for  the  summer, 
are  invariably  benefited,  not  only  as  regards  their  food  capacity  and 
the  ordinary  influences  of  open-air  life,  but  they  acquire  also  greater 
powers  of  resistance,  and  are  thus  less  liable  to  attacks  from  acute  in- 
testinal diseases.    (See  Summer  Resorts,  p.  768.) 

Pneumonia,  Pertussis,  and  Grip. — During  the  colder  months  New 
York  City  children  who  are  convalescing  from  pneumonia,  pertussis,  or 
any  prolonged  illness  which  has  greatly  reduced  them,  will  make  a  much 


774  THE    PRACTICE    OF    PEDIATRICS 

more  rapid  recovery  when  removed  to  Lakewood  or  Atlantic  City, 
where  open-air  life  is  more  easily  secured  than  at  home. 

Malnutrition  and  Digestion  Disorders. — Infants  and  children  suf- 
fering from  chronic  digestive  disorders,  marasmus,  and  malnutrition, 
who  are  given  the  advantages  of  climate  or  open-air  methods  either  in 
the  home  (p.  762)  or  by  a  change  of  residence,  invariably  make  a  more 
rapid  recovery  than  do  those  deprived  of  good  air  because  of  a  lack  of 
appreciation  of  its  value,  or  through  fear  of  the  child's  taking  cold. 

Nephritis. — Again,  there  are  diseases  in  children  in  which  the 
sudden  change  of  temperature,  affecting  the  peripheral  circulation,  may 
be  decidedly  harmful.  Such  conditions  exist  in  slow  convalescence 
from  acute  nephritis,  and  also  in  chronic  nephritis.  These  cases  re- 
quire an  equable  climate,  with  a  permissible  outdoor  hfe,  such  as  is 
furnished  during  our  colder  months  by  Florida  and  Lower  California. 

Asthma. — My  experiences  as  to  the  effects  of  climate  in  asthma 
have  been  contradictory.  As  a  rule,  cold  climates  and  high  altitudes, 
such  as  are  offered  by  the  Adirondacks,  increase  the  asthma,  particu- 
larly if  emphysema  is  also  present.  Nevertheless,  I  have  seen  patients 
who  were  comfortable  only  when  living  under  such  climatic  conditions. 
From  November  1st  to  May  1st  the  best  results  have  been  effected  in 
children  by  a  change  of  residence  from  the  cold  and  changeable  weather 
of  the  Middle  and  Eastern  States  to  Lower  California  or  Florida. 
Residence  at  the  seashore  has  not  been  helpful  to  my  patients.  Older 
children  whose  parents  can  afford  it  should  be  sent  to  a  boarding- 
school,  or  to  some  other  institution  of  learning,  located  where  the  climate 
is  such  as  to  guarantee  freedom  from  attacks. 

Tuberculosis. — The  best  winter  climate  for  a  child  with  pulmonary 
tuberculosis  is  a  dry  climate  with  a  mild  temperature,  neither  high  nor 
low,  but  with  sunshine  in  such  abundance  as  to  permit  a  daily  outdoor 
life.  Such  a  climate  is  found  in  southern  New  Mexico  and  Arizona. 
These  places  furnish  conditions  as  near  to  the  ideal  as  it  is  possible  to 
approach.  The  Adirondacks,  while  furnishing  a  climate  in  winter 
which  may  be  too  severe  for  young  children,  answer  well  for  those  from 
eight  to  nine  years  of  age  in  whom  the  disease  is  not  far  advanced. 

The  Sanitarium. — The  sanitarium  treatment  is  always  to  be  advised 
if  the  patient  can  afford  it,  or  if  it  is  otherwise  available  through 
charity.  Its  advantages  rest  in  the  fact  of  the  discipline,  the  diet,  the 
amount  of  exercise,  the  sleeping  quarters,  the  clothing — in  short,  in  all 
the  details  of  the  life,  every  one  of  which  is  important.  In  a  sani- 
tarium all  these  matters  are  in  the  hands  of  those  who  are  skilled  in  the 
management  of  the  disease,  and  who  direct  each  case  according  to  in- , 
dividual  needs.  Resorts  for  tuberculosis  cases  are  dangerous  because 
of  the  possibilities  of  reinfection  through  the  carelessness  of  others.  In 
a  well-managed  sanitarium,  however,  regulations,  regarding  expectora- 
tion and  the  care  of  the  sputum  reduce  this  danger  to  a  minimum. 
Sanitariums,  however,  are  available  to  but  few  patients.  Many  have 
not  the  means  necessary  to  a  change  of  residence,  and  many  others 
refuse  to  allow  their  children  to  be  separated  from  them,  both  of  which 


COUNTERIRRITANTS  775 

facts  necessitate  the  home  treatment  of  a  great  majority  of  the  cases 
of  pulmonary  tuberculosis  in  young  children  in  our  larger  cities.  (See 
p.  364.) 

COUNTERIRRITANTS 

The  counterirritants  which  I  have  found  especially  useful  in  pedi- 
atrics are  mustard,  capsicum,  turpentine,  camphor,  chloroform,  and 
iodin. 

Counterirritants  are  useful  for  two  purposes — for  the  relief  of  pain 
and  for  the  effect  upon  internal  inflammation  and  congestion.  Without 
doubt  the  diseased  conditions  in  which  counterirritation  is  of  most 
value  are  the  acute  affections  of  the  respiratory  tract,  such  as  bron- 
chitis, bronchopneumonia,  and  pleurisy.  In  acute  bronchitis,  when  the 
terminal  bronchi  are  involved,  when  there  is  cyanosis  and  rapid  respira- 
tion,— from  60  to  80  per  minute, — keeping  the  thorax  enveloped  in  a 
mustard  plaster,  one  part  mustard  to  two  of  flour,'  until  the  skin  is  well 
reddened,  will  often  reduce  the  respirations  from  20  to  30  per  minute, 
BO  that  the  child,  previously  tossing  and  restless,  will  fall  asleep.  I  have 
repeatedly  been  asked  by  nurses  and  mothers  if  the  counterirritation 
could  not  be  applied  more  frequently  because  of  the  apparent  relief 
experienced  by  the  patient.  The  applications  may  often  be  made  with 
advantage  at  intervals  of  from  four  to  six  hours.  They  should  be  sufla- 
ciently  strong  to  produce  the  desired  redness  of  the  skin  in  from  five 
to  ten  minutes.  This  will  usually  be  produced  by  using  at  first  one 
part  of  mustard  to  two  of  flour.  When  the  skin  becomes  tender  from 
the  repeated  applications,  but  one  part  of  mustard  to  five  or  six  of  the 
flour  may  be  required.  If  the  plaster  is  made  too  weak,  it  must  remain 
long  in  contact  with  the  skin,  which  thereby  becomes  macerated. 

Indications. — In  Acute  Inflammations  of  the  Respiratory  Tract. — 
When  the  bronchitis  is  of  the  asthmatic  type,  when  there  is  decided 
bronchial  spasm  associated  with  bronchial  catarrh,  the  counterirri- 
tation furnishes  not  a  little  relief.  In  this  condition  the  whole  thorax 
should  be  enveloped.  In  bronchopneumonia  with  considerable  bron- 
chitis local  applications  of  mustard  over  the  involved  areas  are  to  be 
advised.  The  pain  from  pleuritic  inflammation  occurring  independ- 
ently of,  or  at  the  onset  of,  lobar  pneumonia,  or  developing  during 
bronchopneumonia,  may  be  considerably  relieved  by  counterirritation. 
Here  also  the  mustard  should  be  used  only  over  the  painful  area.  When 
the  pain  is  severe,  equal  parts  of  mustard  and  flour  may  be  used  for  the 
first  application,  if  carefully  watched,  for  a  quick,  sharp  skin  reaction 
should  be  produced.  We  have  no  evidence  that  there  is  any  further 
action  than  that  of  a  sedative  retarding  the  inflammatory  process 
within.  The  mother  or  nurse  should  always  be  cautioned  to  watch  the 
skin  under  a  counterirritant  so  that  a  bHster  shall  not  be  produced. 

During  the  stage  of  engorgement  and  congestion  of  the  bronchi, 
indicated  by  roughened  or  sonorous  breathing  with  occasional  sibilant 
rales,  brisk  counterirritation  with  mustard,  or  with  camphorated  oil 
and  turpentine,  appears  to  hasten  the  progress  of  the  case  toward 


776  THE    PRACTICE    OF    PEDIATRICS 

recovery.  That  a  respiratory  disease  is  ever  aborted  by  these  methods, 
as  claimed  by  some,  is  exceedingly  doubtful.  If  the  turpentine  is  used 
with  the  camphorated  oil,  the  proportion  should  be  one  part  of  turpen- 
tine to  two  parts  of  the  camphorated  oil.  The  mixture  should  be  well 
shaken  before  use  and  applied  vigorously  with  the  hand  for  ten  minutes 
or  until  a  distinct  redness  of  the  skin  is  produced.  The  mustard  or  the 
turpentine  should  be  used  in  these  cases  at  least  three  times  a  day.  I 
know  of  no  condition  where  it  is  necessary  to  blister  a  child's  skin. 
Capsicum  vaselin  may  be  used  in  the  same  way  and  for  the  same  pur- 
pose as  the  camphorated  oil  and  turpentine. 

In  Colic. — In  severe  colic  a  turpentine  stupe  will  often  furnish 
prompt  relief,  twenty  drops  of  turpentine  being  mixed  with  one  pint 
of  water  at  106°F.  Into  this  a  piece  of  flannel  is  dipped,  then  wrung 
sufficiently  dry  not  to  moisten  the  bed-clothing,  and  placed  over  the 
abdomen.  Over  this  is  placed  a  dry  flannel  and  oiled  silk  so  as  to 
retain  the  heat  and  moisture.  The  application  may  be  renewed,  if 
necessary,  every  fifteen  or  twenty  minutes. 

In  Pleurisy  and  Empyema. — When  adhesions  exist  in  emypema  and 
pleurisy,  while  the  pain  is  not  acute,  there  is  an  uncomfortable  drawing, 
dragging  sensation  in  the  chest  which  may  persist  for  months.  This 
has  been  relieved  in  a  few  of  my  cases  by  the  tincture  of  iodin,  U.  S.  P., 
painted  over  the  painful  parts  every  third  or  fourth  night. 

In  Intercostal  Neuralgia. — In  intercostal  neuralgia,  not  infrequently 
seen  in  overworked  school-girls,  the  repeated  application,  at  intervals 
of  three  or  four  days,  of  tincture  of  iodin  over  the  point  of  exit  of  the 
involved  nerve  will  often  be  followed  by  complete  cessation  of  the  pain. 

Acute  Articular  Rheumatism. — For  the  pain  in  acute  articular  rheu- 
matism, chloroform  liniment,  U,  S.  P.,  may  be  applied  to  the  joint,  or, 
better,  the  solution  of  lead  and  opium,  U.  S.  P.,  may  be  applied  warm  in 
old  linen  covered  with  oiled  silk. 

COLD  SPONGING  IN  FEVER 

Sponging  with  plain  water,  with  salt  water  (a  teaspoonful  of  salt  to 
a  pint  of  water),  or  with  alcohol  and  water  (one  part  alcohol  to  three 
parts  water)  is  a  means  of  reducing  high  temperature,  with  which  every 
physician  should  be  familiar.  Cool  sponging  at  75°F.  to  80°F.,  plain  or 
medicated,  is  useful  for  two  purposes :  as  a  sedative  and  for  the  reduc- 
tion of  fever.  In  measles  or  scarlet  fever,  although  the  temperature 
may  not  be  high,  the  itching  and  burning  of  the  skin  prevent  sleep,  and 
the  patient  is  very  uncomfortable,  but  often,  under  such  conditions, 
he  will  fall  asleep  during  a  careful  sponging.  In  pneumonia,  in  typhoid 
fever,  and  in  the  intestinal  disorders  of  summer,  my  nurses  have  a 
standing  order  to  give  a  cold  sponging  for  fifteen  minutes  at  any  time 
when,  in  their  judgment,  it  may  be  indicated,  not  on  account  of  the 
fever,  but  because  of  the  sedative  effect  upon  the  patient.  A  sponging 
of  ten  to  fifteen  minutes  three  or  four  times  a  day  with  cool  water  (65° 
to  75°F.)  will  greatly  help  a  baby,  whether  sick  or  well,  to  pass  suc- 
cessfully through  the  hot  days  of  summer. 


THE    COOL    PACK  777 

Sponging  for  fever,  while  possessing  less  antipyretic  value  than 
do  other  measures,  such  as  a  cold  pack,  for  example,  has  the  advantage 
in  that  it  is  safe  and  easy  of  application  in  the  hands  of  the  most  un- 
skilled, and  will  be  of  assistance  in  influencing  high  temperature  when 
other  means  are  not  available.  In  order  not  to  antagonize  or  frighten 
timid  children,  it  is  often  wise  to  begin  with  the  water,  whether  plain  or 
medicated,  at  95°F.,  and  reduce  the  temperature  gradually  by  the 
addition  of  cold  water  or  small  pieces  of  ice.  It  is  rarely  necessary  to 
go  below  60°F.,  and  usually  the  sponging  should  not  be  continued 
longer  than  thirty  minutes.  It  is  well  to  have  an  interval  of  rest — from 
thirty  to  ninety  minutes — between  the  spongings,  as  too  frequent 
sponging,  if  resisted,  may  exhaust  the  patient.  Every  part  of  the  body 
should  be  sponged  in  turn,  but  it  is  not  necessary  to  expose  the  patient, 
who  should  be  covered  with  a  flannel  blanket.  When  the  process  is 
completed,  the  skin  should  be  briskly  rubbed  for  a  few  minutes  with  a 
dry,  rough  towel. 

THE  COOL  PACK 

The  cool  pack,  properly  applied,  is  free  from  the  slightest  danger  to 
the  patient,  and  is  the  best  means  we  possess  with  which  to  combat  a 
continued  high  fever.  The  pack  may  be  used  freely  and  with  as  much 
success  in  treating  the  exanthemata  as  in  dealing  with  typhoid  fever  or 
pneumonia.  That  cool  water  may  not  safely  be  applied  to  the  skin  of 
a  child  with  scarlet  fever  is  a  fallacy  which  it  is  our  duty  to  explain 
to  mothers. 

The  pack  is  prepared  as  follows,  a  rubber  sheet  being  used  to  protect 
the  bed-sheet:  A  large  bath-towel,  or  some  thick,  soft,  absorbent 
material,  should  be  used.  Muslin,  linen,  or  any  thin  material  does  not 
answer  so  well.  Slits  are  cut  in  the  towel  large  enough  for  the  arms  to 
pass  through,  and  the  towel  is  folded  around  the  body,  enveloping  only 
the  trunk  and  buttocks  (Fig.  114).  The  pack  shoud  not  extend  below 
the  middle  of  the  thighs.  This  leaves  the  arms  and  the  greater  part  of 
the  lower  extremities  free.  A  hot-water  bag,  carefully  guarded,  should 
be  placed  at  the  feet  and  the  patient  covered  with  a  blanket  of  medium 
weight.  The  towel  is  moistened  with  w^ater  at  95°F.  This  higher 
temperature  is  necessary  at  first  in  order  not  to  frighten  the  patient, 
as  sudden  cold  is  apt  to  do,  and  also  to  avoid  shock.  In  two  or  three 
minutes  the  towel,  without  being  removed,  is  again  moistened  with 
water  at  90°F.,  later  with  water  at  85°F.,  and  still  later,  at  80°F. 
When  the  temperature  of  the  water  reaches  80°F.,  it  should  be  main- 
tained at  this  point  for  half  an  hour,  when  the  patient's  temperature 
should  again  be  taken.  If  at  the  beginning  his  temperature  was  105°F. 
and  now  shows  little  or  no  reduction,  the  temperature  of  the  water  with 
which  the  towel  is  moistened  should  be  reduced  to  70°F.,  or,  if  necessary, 
even  to  60°F.  The  child  throughout,  need  not  be  disturbed,  except  to 
be  turned  from  side  to  side  in  order  to  wet  the  towel  with  water  of  the 
desired  temperature,  this  being  one  of  the  advantages  of  the  pack  over 
a  tub-bath  or  sponging.     The  towel,  or  other  material  employed,  should 


778 


THE    PRACTICE    OF   PEDIATRICS 


not  be  used  for  more  than  six  hours  without  being  replaced  by  a 
fresh  one. 

For  the  j&rst  hour  or  two  in  a  pack  the  temperature  of  the  patient 
should  be  taken  every  half -hour.  When  it  is  reduced  to  102°F.,  the 
pack  should  be  removed,  for,  if  it  is  continued  longer,  too  great  a  reduc- 
tion may  take  place.  If  the  fever  rises'  again  rapidly  to  105°F.  or 
higher  it  is  well  to  keep  the  patient  in  the  pack  continuously.  The 
degree  of  cold  necessary,  in  the  individual  case,  to  keep  the  temperature 
within  safe  limits  will  soon  be  learned.  I  recently  kept  in  a  pack  for 
seventy-two  hours  a  boy  four  years  old  with  lobar  pneumonia.  In 
this  case  a  continuous  pack  of  70°F.  was  required  to  keep  the  tempera- 
ture at  104°F.  or  slightly  lower. 

Another  reason  for  frequently  taking  the  temperature  is  that,  early 
in  the  attack,  we  do  not  know  how  the  fever  will  be  affected  by  the  con- 
tinued cool  applications.  In  some  children  it  is  very  readily  influenced, 
and  in  such  a  case  coUapse  might  follow  a  very  sudden  reduction  of  the 


Fig.  114. — The  cool  pack. 

temperature.  In  cases  readily  controlled,  the  pack  may  be  necessary 
for  only  one-half  hour  or  an  hour,  at  intervals  of  three  or  four  hours. 
An  ice-bag  may  with  advantage  be  kept  at  the  head  when  the  child  is 
in  the  pack.  Suddenly  enveloping  the  entire  skin  surface  in  a  cold 
sheet  at  70°F.,  as  advocated  by  some  writers,  may  increase  the  tem- 
perature and  occasion  grave  symptoms  of  impending  death,  because  of 
the  sudden  contraction  of  the  superficial  blood-vessels,  which  sends  the 
blood  to  the  viscera,  producing  congestion  of  the  internal  organs. 

BATHS 

The  newly  born  child  should  be  given,  daily,  a  basin-bath  with  luke- 
warm, boiled  water  and  Castile  soap  until  the  cord  falls  and  the  navel 
heals.  When  this  has  taken  place,  the  tub-bath  may  be  given.  The 
temperature  of  the  bath  for  the  very  young  infant  should  not  be  below 
95°F.  nor  above  100°F.  Very  young  children  should  not  be  kept  in 
the  water  more  than  three  minutes.  After  the  third  or  fourth  month 
a  temperature  of  90°  to  95°F.,  is  best,  the  child  being  kept  in  the  water 
about  five  minutes.     At  this  age  I  prefer  to  have  the  tub-bath  given  at 


BATHS 


779 


il 


night,  just  before  the  child  is  put  to  bed.  A  basin-bath  may  be  given 
in  the  morning.  When  the  child  is  a  year  old  and  fairly  vigorous,  the 
temperature  of  the  water  at  the  beginning  of  the  bath  should  be  90°F. 
This  should  gradually  be  reduced  to  80°F.  by  the  addition  of  cold  water, 
the  child  being  vigorously  rubbed  with  the  hand  while  in  the  water. 
The  temperature  of  the  room  should  be  from  76°F  to  80°F.  during  the 
bath,  and  windows  and  doors  should  be  closed.  When  removed  from 
the  tub  the  baby  should  be  dried  quickly  and 
thoroughly,  and  the  folds  of  the  skin  should  be  well 
powdered.  A  sponge  should  never  be  used  in  any 
portion  of  the  bathing  process  and  should  never  be  in- 
cluded in  the  nursery  outfit.  It  is  never  clean  after  it 
has  once  been  used.  Some  children  have  a  dread  of 
the  bath,  and  cry  frantically  when  placed  in  the 
water.  This  is  due  to  fear,  and  may  usually  be  over- 
come by  placing  a  sheet  over  the  tub  and  lowering 
the  child  on  it  into  the  water. 

The  Cold  Douche. — For  "runabouts"  from  two  to 
three  years  old  it  may  not  be  wise  to  use  water  below' 
70°F.,  but  many  children  over  three  years  have  the 
water  applied  in  the  form  of  a  cold  douche  after  the 
cleansing  bath,  during  the  entire  twelve  months,  at  the 
temperature  at  which  it  runs  from  the  faucet.  In 
winter,  in  New  York  houses,  this  ranges  from  50°  to 
60°F. 

In  giving  the  cool  douche  the  child  should  stand 
in  warm  water  covering  the  ankles.  The  douche  may 
be  used  in  the  form  of  a  spray  or  shower,  or  the  water 
may  be  applied  by  means  of  a  sponge  at  the  desired 
temperature.  The  head,  if  the  shower  or  spray  is 
used,  should  be  suitably  protected  by  an  oilskin  or 
rubber  bathing  cap. 

After  the  cold  douche  there  should  be  a  vigorous 
friction  of  the  skin  with  a  rough  towel.  If  there  is 
not  a  quick  reaction,  if  the  skin  does  not  become  warm 
and  glowing,  warmer  water  should  be  used.  So  also 
with  blueness  of  the  extremities  and  "goose  flesh," 
water  less  cold  should  be  used,  but  the  douche  should 
not  be  discontinued. 

In  the  great  majority  of  homes  the  bathing  of  the  children  can  be 
carried  on  with  greater  convenience  immediately  before  their  bed-time. 
The  child  should  receive  the  warm  bath  and  the  cool  douche,  and  then, 
in  night-clothes,  a  warm  wrapper,  and  suitable  foot  covering,  he  should 
eat  his  supper.  However,  if  this  time  is  not  convenient,  he  maj^  be 
given  the  evening  meal  at  5.30  or  6.30,  followed  in  one  hour  by  the  bath 
and  bed. 

Tub -baths  for  Fever. — Place  the  child  in  water  at  a  temperature  of 
95°F.  and  reduce  to  80°F.  or  75°F.  by  the  addition  of  ice  or  cold  water. 


Fig.  115.— Bath 
thermometer. 


780  THE    PRACTICE    OF    PEDIATRICS 

The  duration  of  the  bath  should  not  be  more  than  ten  minutes,  constant 
friction  being  maintained  during  the  entire  process. 

Basin  Bathing  for  Fever. — Add  eight  ounces  of  alcohol  to  a  quart 
of  water  at  a  temperature  of  70°F.  The  child  is  stripped,  covered  with 
a  flannel  blanket,  and  the  entire  body  sponged  with  this  solution  for 
ten  or  fifteen  minutes.  Drying  the  skin  should  not  be  practised.  Al- 
low the  alcohol  and  water  to  evaporate  from  the  body  surface,  as  by 
this  means  a  greater  reduction  in  the  temperature  will  be  affected. 

Either  the  tub-bath  or  the  basin-bath  may  be  used  by  the  mother 
in  case  of  sudden  high  fever — 104°  to  105°F. — before  the  physician 
arrives.     She  should  be  so  instructed. 

Bathing  for  Comfort  in  Hot  Weather. — The  basin-bath  and  tub- 
bath  may  also  be  used  as  a  means  of  relief  during  very  hot  weather. 
One  or  two  basin-baths  a  day,  with  a  tub-bath  at  bed-time  during  this 
trying  season,  will  give  the  child  much  relief,  and  help  him  to  pass 
safely  through.  The  very  young  feel  the  extreme  heat  most  acutely, 
and  endure  it  with  difficulty.  I  know  of  nothing  else  that  will  give  a 
restless,  uncomfortable,  heat-tormented  child  such  a  refreshing  sleep 
as  will  a  cool  tub-  or  basin-bath. 

Mustard  Bath. — A  mustard  bath  is  prepared  by  adding  a  heaping 
tablespoonful  of  mustard  to  six  gallons  of  warm  water.  From  five  to 
ten  minutes  in  the  bath  is  all  that  is  advisable  to  allow.  The  special 
use  of  the  mustard  bath  is  in  the  treatment  of  convulsions;  it  will  be 
found  useful  also  for  nervous  children  who  sleep  badly.  Two  or 
three  minutes  in  the  mustard  water,  followed  by  a  quick  rubbing 
immediately  before  going  to  bed,  are  oftentimes  all  that  will  be  re- 
quired to  induce  refreshing  sleep. 

Brine  Bath. — A  brine  bath — an  even  tablespoonful  of  salt  to  one 
gallon  of  water  at  a  temperature  of  95°F. — is  of  great  service  with  very 
delicate,  poorly  nourished  children.  Its  action  is  that  of  a  tonic.  If 
the  child  is  thoroughly  soaped  and  washed  with  plain  water  and  then 
immersed  in  the  brine  bath,  no  further  rubbing  is  necessary.  The 
child  should  be  kept  in  the  bath  for  five  or  ten  minutes,  constant  fric- 
tion being  continued  during  the  entire  time.  The  brine  bath  is  not 
applicable  to  children  with  intertrigo  or  eczema. 

Soda  Bath. — The  soda  bath  is  of  some  service  in  cases  of  prickly 
heat,  from  which  many  children  suffer  during  the  summer.  A  table- 
spoonful of  bicarbonate  of  soda  should  be  added  to  each  half  gallon  of 
water  used.  The  temperature  of  the  water  should  be  that  to  which  the 
child  is  accustomed.  From  two  to  four  minutes  in  the  water  suffices. 
There  should  be  little  or  no  friction  of  the  skin.  The  child  should  be 
dried  with  soft  towels. 

Bran  Bath. — The  bran  bath  also  is  of  service  in  prickly  heat.  One 
cup  of  bran  is  mixed  with  the  water  in  the  bath-tub  and  the  same 
method  employed  as  for  the  soda  bath. 

Starch  Bath. — The  starch  bath  is  also  useful  in  prickly  heat.  One- 
half  cupful  of  powdered  laundry  starch  is  mixed  with  the  water  in  the 
bath-tub,  and  the  same  method  employed  as  for  the  soda  bath. 


UNPALATABLE    AND    NAUSEATING    DRUGS  781 

Hot  Bath. — The  child  is  placed  from  three  to  five  minutes  in  water 
which  has  been  raised  to  a  temperature  of  105°  or  110°F.  Constant 
friction  of  the  extremities  is  maintained  during  the  bath. 

BATHING  THE  SICK 

There  is  a  pronounced  objection  among  many  to  bathing  children 
when  ill,  particularly  when  they  are  suffering  from  respiratory  diseases 
or  from  the  exanthemata.  The  functions  of  the  skin  as  an  organ  of 
excretion  and  elimination  are  most  important,  and  it  is  absolutely  nec- 
essary that,  during  illness,  when  the  metabolic  processes  of  the  body 
are  being  carried  on  to  an  excessive  degree,  all  the  eliminating  organs  be 
kept  in  the  best  possible  condition  in  order  that  they  may  the  better  do 
their  work.  Therefore  to  perform  its  functions  properly  the  skin  must 
receive  proper  attention,  and  there  is  no  better  means  of  stimulating  it 
to  a  sharp  reaction  than  bathing  with  weak  salt  water — a  teaspoonful 
of  salt  to  a  gallon  of  water — at  a  temperature  of  85°  to  90°F.,  followed 
by  a  brisk  rubbing.  Every  sick  child  should  receive  a  sponge-bath 
at  least  once  daily.  It  is  the  sudden  contact  of  cold  air  with  the  moist 
skin  which  occurs  sometimes  in  undressing  a  child,  without  the  attend- 
ant reaction,  that  causes  the  shock,  the  "cold,"  which  is  usually 
attributed  to  the  bath.  It  is  the  temperature  of  the  room  in  which  the 
child  is  undressed,  the  careless  method  of  bathing,  and  not  the  applica- 
tion of  water,  which  cause  the  trouble.  Even  the  danger  of  this  ex- 
posure is  greatly  overestimated.  In  order  to  avoid  every  possible 
danger,  however,  the  temperature  of  the  room  in  which  the  sick  or 
delicate  child  is  bathed  should  be  raised  to  80°F.  I  have  yet  to  know 
of  a  child  who  suffered  from  the  effects  of  a  bath  properly  given,  and  I 
know  of  hundreds  who  have  suffered  because  of  its  absence. 

UNPALATABLE  AND  NAUSEATING  DRUGS 

It  is  impossible  to  mention  in  detail  all  the  drugs  which  might  be 
included  under  this  heading.  Only  those  will  be  referred  to  which  we 
are  obliged  to  use  almost  daily  in  our  work — drugs  which  are  either  un- 
pleasant to  the  taste  or  which  may  be  badly  borne  by  the  stomach,  or 
drugs  combining  both  these  disadvantages.  How  to  administer  certain 
drugs  so  that  their  use  may  be  continued  and  yet  not  interfere  with  the 
digestive  function  is  a  question  which  deeply  concerns  those  who  may 
have  children  for  their  patients.  The  element  of  taste  is  a  most  impor- 
tant one  to  a  child ;  therefore,  when  possible,  drugs  disagreeable  to  the 
taste  should  be  given  to  children  in  tablet  or  pill  form  or  in  capsule. 
The  continued  use  of  a  drug  oftentimes  depends  upon  its  being  made 
palatable.  As  a  general  rule,  when  pills,  tablets,  or  capsules  are  given, 
one-half  glass  of  water  should  be  taken  at  the  same  time,  in  order  to 
diminish  any  possible  irritant  effects  upon  the  mucous  membrane  of 
the  stomach. 

Salicylate  of  Soda. — Salicylate  of  soda  is  a  drug  disagreeable  in  taste 
and  very  liable  to  destroy  the  appetite  and  interfere  with  digestion. 


782  THE    PRACTICE    OF    PEDIATRICS 

In  acute  rheumatism  its  use  is  invaluable,  and  we  are  obliged  often- 
times to  give  it  in  large  doses.  It  is  best  given  after  meals  with  one- 
half  glass  of  milk.  Fairly  large  doses  at  this  time,  well  diluted,  are 
better  than  more  frequent  smaller  doses.  This  drug  usually  is  better 
borne  if  given  m  solution  with  peppermint-water  or  with  simple  elixir 
diluted  50  per  cent,  with  water;  but  the  taste  when  thus  given  is  only 
partially  disguised,  and  being  still  very  objectionable  to  many,  may  be 
prevented  by  the  use  of  a  capsule  if  the  patient  is  old  enough,  care  being 
taken  to  give  a  considerable  amount  of  water  or  milk  with  each  capsule. 

lodid  of  Potash. — This  drug  is  indispensable  and  is  one  for  which 
no  other  can  be  substituted.  It  is  best  given  in  solution.  It  is. most 
disagreeable  in  taste  and  directly  irritant  to  the  mucous  membrane 
of  the  stomach.  Like  salicylate  of  soda,  it  should  be  given  after  meals 
with  one-half  to  one  glass  of  water  or  milk.  It  is  best  given  plain,  as 
the  saturated  solution,  which  may  be  dropped  into  the  milk. 

Bichlorid  of  Mercury. — This  drug  is  usually  given  in  such  small 
doses  that  its  irritant  properties  are  but  little  felt.  It  is  best  prescribed 
in  tablet  form,  dissolved  in  two  teaspoonfuls  of  water  and  followed  by 
a  swallow  of  water.     When  possible,  it  should  be  given  after  feeding. 

Alcohol. — Alcohol  is  another  drug  which  should  be  given  well 
diluted,  regardless  of  the  form  in  which  it  is  administered.  It  is  best 
given  with  or  after  food,  but  it  should  always  be  given  diluted  with 
at  least  six  parts  of  water,  if  whisky  or  brandy  is  used. 

Ipecac  and  Tartar  Emetic. — Ipecac  and  tartar  emetic,  when  em- 
ployed as  expectorants,  are  best  given  with  sugar  of  milk  in  powder 
or  tablet  form.  They  should  never  be  given  on  an  empty  stomach. 
Two  or  three  teaspoonfuls  of  water  should  precede  their  administration 
when  they  are  not  given  within  a  reasonable  time  after  feeding.  In 
many  children,  when  given  without  this  precaution  even  in  the  usual 
doses,  they  will  often  decrease  the  appetite  and  the  digestive  capacity. 

The  Ammonium  Salts. — Carbonate  of  ammonia  must  always  be 
given  in  solution  and  should  always  be  well  diluted  with  water.  Mu- 
riate of  ammonia  may  be  used  in  tablet  or  powder  form.  Water  or 
milk  should  precede  the  administration  of  either.  One  part  of  simple 
elixir  with  two  parts  of  water  makes  an  agreeable  combination. 

Oils. — Oils  used  for  nutritive  purposes  should  invariably  be  given 
after  meals.  Plain  cod-liver  oil  or  any  of  the  preparations  containing 
it  should  never  be  given  on  an  empty  stomach. 

Castor  Oil. — Castor  oil  is  best  given  when  the  stomach  is  empty. 
A  much  more  prompt  and  satisfactory  cathartic  effect  is  thus  produced. 
The  oil  may  be  given  in  soda-water  or  coffee,  with  orange-juice,  or  in 
peppermint- water.  Older  children  sometimes  take  oil  better  plain, 
sandwiched  between  the  two  halves  of  a  peppermint  cream,  first  the 
candy,  then  the  oil,  followed  by  the  remainder  of  the  candy.  If  castor 
oil  is  vomited,  it  riiay  be  repeated  in  a  few  minutes,  and  often  will  then 
be  retained. 

Creosote. — Creosote  is  most  difficult  of  administration  to  many 
children.     I  usually  prescribe  the  carbonate,  which  is  ordered  to  be 


ALCOHOL  783 

dropped  into  one  or  two  teaspoonfuls  of  wine  after  meals.     It  may 
also  be  given  in  soft  capsules  or  in  an  emulsion. 

Quinin. — Quinin  should  be  given  in  solution  or  in  capsule.  Quinin 
pills  as  they  are  sometimes  made,  with  an  insoluble  coating,  pass  un- 
changed through  the  entire  intestinal  canal.  For  purposes  of  solution 
a  most  satisfactory  menstruum  is  a  preparation  of  yerba  santa,  known 
to  the  trade  as  Yerberzine  (Lilly).  The  bisulphate  should  always  be 
prescribed  for  children,  for  the  reason  that  it  may  be  given  in  complete 
solution  without  the  addition  of  acid. 

Strychnin. — Strychnin,  on  account  of  its  taste,  is  often  strenuously 
objected  to,  and  is,  therefore,  better  given  in  tablet  triturate  form.  If 
the  tablet  cannot  be  swallowed,  it  may  be  broken  into  small  pieces  (not 
powdered)  and  mixed  with  a  teaspoonful  of  orange  pulp  or  in  a  thick 
cereal  jelly. 

Digitalis. — Digitalis,  when  the  tincture  or  the  infusion  is  used, 
should  never  be  given  when  the  stomach  is  empty.  It  should  be  ad- 
ministered after  meals  or  the  drinking  of  water  or  milk.  There  are  few 
drugs  that  will  so  completely  destroy  a  child's  desire  for  food  as  the 
digitalis  preparations  when  put  into  an  empty  stomach. 

Tincture  of  Muriate  of  Iron. — The  tincture  of  muriate  of  iron  should 
be  given  after  meals,  well  diluted,  in  at  least  one-half  glass  of  water. 
The  child  should  take  the  medicine  through  a  glass  tube  so  as  not  to 
injure  the  teeth.  Iron  preparations  generally  should  be  given  after 
meals,  and  in  case  the  liquid  preparations  are  used,  they  should  be  well 
diluted  with  water. 

ALCOHOL 

In  its  relation  to  children,  alcohol,  regardless  of  the  form  in  which 
it  is  used,  must  always  be  considered  as  a  drug  and  not  as  a  beverage. 
It  is  occasionally  of  great  service  in  diseases  of  children.  Under  cer- 
tain conditions  it  answers  better  than  any  other  means  of  stimulation  we 
possess.  The  fact  that  it  is  grossly  misused  does  not  in  any  way  de- 
tract from  its  value  in  illness.  It  is  too  often  given,  chiefly  for  the 
reason  that  its  use,  in  the  form  of  whisky  and  brandy  and  wine,  is  ad- 
vocated in  medical  work  in  many  of  the  ordinary  ailments  of  childhood 
where  really  it  is  absolutely  contraindicated.  Its  use,  in  my  hands, 
has  been  that  of  a  food  and  stimulant  in  very  grave  conditions,  the 
duration  of  its  usefulness  being  often  completed  in  a  day  or  two. 
When  given  to  children  for  a  prolonged  period,  even  in  moderate 
quantities,  it  invariably  interferes  with  digestion  and  assimilation,  and 
therefore  does  harm.  It  is  very  liable  also  to  act  as  an  additional 
irritant  to  the  kidneys,  which  are  prone  to  show  inflammatory  changes 
as  a  result  of  the  systemic  toxemia  due  to  the  disease.  We  have 
heart  stimulants  which  are  ordinarily  as  effective  as  alcohol  and  with- 
out its  danger  either  to  the  stomach  or  the  kidneys. 

It  is  my  practice  never  to  give  alcohol  early  in  an  illness  unless  the 
onset  is  accompanied  by  profound  prostration,  but  rather  to  hold  this 
drug  in  reserve  until  it  is  absolutely  necessary.     Used  in  this  way,  it  has 


784  THE    PRACTICE    OF    PEDIATRICS 

been  of  much  service  in  two  conditions  in  which,  in  my  opinion, 
nothing  can  replace  it.  I  refer,  first,  to  that  time  which  may  arise  in 
any  grave  disease  when  the  heart  fails  to  respond  to  the  usual  stimula- 
tion, as  in  the  crisis  of  lobar  pneumonia  and  in  the  profound  toxemia  of 
scarlet  fever  or  diphtheria.  At  such  a  time  the  powers  of  assimilation 
for  most  drugs  as  well  as  for  food  are  reduced  to  a  minimum.  When 
food  is  rejected,  or  taken  badly,  when  the  usefulness  of  strychnin, 
strophanthus,  musk,  camphor,  digitalis,  and  caffein  has  been  exhausted, 
alcohol  should  be  given  and  given  in  as  large  doses  as  may  be  required 
to  produce  the  desired  results.  It  is  astonishing  what  large  quantities 
of  alcohol  may  be  given  without  the  slightest  intoxicating  effects  in 
many  such  conditions.  When  given  well  diluted  it  is  usually  well 
borne  and  assimilated;  it  supports  the  heart,  improves  the  respiration, 
and  often  will  carry  the  patient  through  to  a  successful  convalescence 
even  when  the  outlook  is  very  unpromising.  As  the  system  readily 
becomes  accustomed  to  alcohol,  it  must  be  given  in  increasing  doses. 
If  it  is  begun  early  in  the  illness,  it  will  have  lost  its  stimulating 
effects  by  the  time  it  is  most  needed.  Brandy  or  whisky,  well  diluted, 
is  the  form  in  which  it  is  generally  used. 

The  second  condition  in  which  alcohol  is  useful  is  in  cases  with 
greatly  lowered  vitality  resulting  from  some  severe  illness,  such  as 
typhoid  fever,  enterocolitis,  or  pneumonia.  If  a  child  is  suffering  from 
shock  bordering  on  collapse,  or  collapse  with  a  subnormal  temperature 
with  all  the  vital  powers  at  a  low  ebb,  alcohol  will  do  much  to  sustain 
him  until  he  is  able  to  assimilate  easily  digested  or  predigested  foods. 
In  such  cases  whisky,  well  diluted, — 1  part  whisky  to  6  parts  of  water, 
— given  at  intervals  of  two  or  three  hours,  will  hasten  recovery.  If 
the  child  cannot  swallow,  the  whisky  may  be  given  by  gavage;  if  vom- 
ited, double  the  quantity,  well  diluted,  may  be  given  by  the  rectum. 
Its  hypodermic  use  is  infrequently  resorted  to  chiefly  for  the  reason 
that  other  remedies,  such  as  strychnin  and  digitalis,  are  more  effective 
than  alcohol  when  so  given.  The  doses  vary  from  5  drops  to  3^^  dram 
every  one  or  two  hours,  12  to  24  doses  in  twenty-four  hours,  for  a  child 
one  year  of  age.  A  child  two  years  of  age  may  be  given  1  dram  at  in- 
tervals of  one  or  two  hours.  The  use  of  alcohol  is  attended  with  the 
least  disturbance  when  it  is  given  after  the  feedings. 

HEAT  AS  A  THERAPEUTIC  AGENT 

Heat  has  long  been  used  as  a  therapeutic  measure.  For  infants 
and  children  it  has  a  wide  range  of  usefulness,  both  as  dry  heat  and 
when  conveyed  by  the  use  of  water  as  a  vehicle. 

Moist  Heat. — Heat,  water-borne,  is  used  as  follows: 

In  colic  and  indigestion  and  as  a  diuretic,  internally. 

In  acute  gastritis,  as  a  sedative,  taken  by  sipping. 

In  convulsions,  idiopathic  and  uremic,  by  means  of  baths. 

In  convulsions,  idiopathic  and  uremic,  as  colon  flushings,  105°  to 
110°F. 

In  colic,  as  a  hot  stupe  applied  to  the  abdomen. 


COLD  AS  A  THERAPEUTIC  AGENT  785 

In  torticollis,  as  a  hot  compress  to  the  neck. 

In  sprains,  as  a  hot  compress  to  the  joint  or  muscle. 

In  acute  articular  rheumatism,  as  a  hot  compress  to  the  joint. 

In  retention  of  the  urine,  as  a  hot  compress  appHed  to  the  lower 
abdomen  and  bladder. 

In  suppression  of  the  urine  {acute  nephritis),  as  a  poultice  or  hot 
compress  over  the  kidneys  and  in  colon  flushings,  105°  to  110°F. 

In  cerebrospinal  meningitis,  as  a  hot  bath  or  hot  compress  to  the 
trunk  and  lower  extremities. 

In  pleurisy,  as  a  hot  compress  to  the  painful  area. 

In  acute  angina,  as  a  gargle. 

In  conjunctivitis,  as  a  hot  compress. 

To  hasten  suppuration  in  an  abscess,  as  a  poultice  or  compress. 

In  retropharyngeal  abscess  and  in  peritonsillitis  (quinsy) ,  as  a  throat 
douche. 

In  earache,  as  a  douche  or  by  means  of  a  hot-water  bag. 

In  toothache,  by  means  of  a  hot-water  bag,  or  as  hot  water  held  in 
the  mouth. 

In  facial  neuralgia,  by  means  of  a  hot-water  bag. 

In  prematurity  and  in  lowered  vitality  or  reduced  temperature  after 
disease,  by  hot- water  bags  or  bottles. 

Dry  Heat. — Dry  heat  is  used  in  the  following  conditions: 

In  prematurity,  lowered  vitality,  or  reduced  temperature  after  disease, 
by  means  of  the  electrotherm. 

In  suppression  of  the  urine  (acute  nephritis),  by  the  electrotherm  or 
by  hot  air  (p.  447). 

In  using  heat  with  children  caution  should  be  exercised  as  to  the 
degree  employed.  Serious  burning  accidents  have  occurred  by  the 
use  of  hot-water  bottles  and  hot  compresses.  When  it  is  used  very 
hot,  the  hot-water  bottle  should  be  guarded  by  wrapping  it  in  flannel. 
Moist  heat  in  the  form  of  compresses,  poultices,  and  stupes  should 
always  be  tested  by  placing  the  vehicles  against  the  face  of  the  atten- 
dant. The  adult  hand  will  often  bear  a  greater  degree  of  heat  than  is 
safe  to  apply  to  the  skin  of  an  infant  or  young  child.  In  using  hot 
packs,  hot-water  bags,  the  electrotherm,  or  dry  heat,  generated  by 
a  lamp  or  other  device,  such  as  the  Kilmer  kettle,  a  thermometer 
should  be  placed  between  the  child's  clothing  and  the  bed-cloth- 
ing. A  temperature  of  110°F.  is  the  highest  to  use  with  children. 
When  water  is  the  vehicle,  the  patient  must  be  most  carefully  watched 
and  the  application  frequently  renewed  because  of  the  rapid  evapora- 
tion. A  compress  or  poultice  must  not  be  allowed  to  get  cool.  A 
piece  of  flannel  or  oiled  silk  or  rubber  tissue  over  a  hot  compress  will 
obviate  the  necessity  for  frequent  changes. 

COLD  AS  A  THERAPEUTIC  AGENT 

In  the  treatment  of  children,  cold  is  generally  used  in  the  form 
of  compresses,   baths,   or  packs,   and  is  indicated  in   the  following 
conditions : 
50 


786  THE    PRACTICE    OF    PEDIATRICS 

In  tonsillitis,  acute  'pharyngitis,  and  headache,  in  the  form  of  a  cold 
compress. 

In  meningitis  and  pyrexia,  by  means  of  the  ice-bag  or  the  cool  coil. 

In  appendicitis,  by  means  of  the  ice-bag. 

In  endocarditis  and  pericarditis,  by  means  of  the  ice-bag. 

In  fever,  by  means  of  baths,  cold  packs,  sponging,  and  in  older  chil- 
dren, by  colon  flushings.     (Not  lower  than  70°F.  when  used  thus.) 

In  adenitis  and  in  threatened  superficial  abscess,  by  means  of  an  ice- 
bag. 

In  hysteric  and  neurotic  children,  as  a  spinal  douche. 

In  malnutrition  in  older  children  as  a  tonic,  by  means  of  a  moderate 
cool  spinal  douche  following  a  warm  bath. 

For  further  details  as  to  the  application  of  cold  in  special  diseases 
the  reader  is  referred  to  the  discussion  of  the  diseases  in  question. 

BLOOD  TRANSFUSION  AND  INTRAMUSCULAR  INJECTION 

Blood  transfusion*  has  been  practised  in  some  form  since  the  dis- 
covery by  Harvey  of  the  circulation;  and  devices  to  accomplish  the 
transfer  of  blood  were  employed  by  Folli,  and  des  Gabets,  a  Benedic- 
tine monk  as  early  as  the  middle  of  the  seventeenth  century.  Authen- 
tic accounts  moreover  exist  recording  successful  operations  in  trans- 
fusion by  Richard  Lower  and  by  Jean  Denys  in  the  years  1666-1667, 
while  in  1667  Denys  and  King  successfully  transfused  blood  from  a 
sheep  to  a  man  by  means  of  two  cannulas  united  by  a  section  of  carotid 
artery  taken  from  a  horse  or  ox.  As  a  means  of  injecting  blood  the 
syringe  was  employed  by  James  Blundell  in  1818.  Later  forms  of 
apparatus  were  all  modifications  of  a  direct  connecting  mechanism  of 
some  sort  such  as  that  of  Lower,  or  of  a  "conducting  system"  supple- 
mented by  an  "impellor"  or  syringe. 

During  the  past  quarter  of  a  century  the  practice  of  transfusion 
which  for  many  years  was  held  in  disrepute  because  of  fatalities  (many 
of  which  were  due  to  antagonistic  action  between  the  blood  of  donor 
and  that  of  recipient),  has  been  revived  with  remarkably  good  results 
and  the  technic  has  been  simplij&ed  sufficiently  to  render  the  opera- 
tion relatively  free  from  risk  in  ordinary  hands.  The  successful  but 
difficult  methods  of  Carrel  and  Crile  have  now  given  place  to  the  Linde- 
mann  method  of  transfusion  by  the  syringe  and  cannula  system,  and 
this  procedure  in  turn  has  been  improved  upon  by  the  modification  of 
Ungerf  which  consists  in  the  employment  of  a  stopcock  controlling  a 
syringe  which  transfers  the  blood  from  donor  to  recipient,  at  the  same 
time  permitting  the  systematic  flushing  of  the  connected  cannulse 
with  saline  solution  from  a  second  syringe  which  forms  part  of  the 
apparatus. 

Most  of  the  bad  results  ascribed  to  transfusion  in  the  past  have  been 
due  either  to  incompatibility  of  blood,  i.e.,  "hemolysis  or  agglutination 

*  Hooker  and  Satterlee  in  Johnson's  "Operative  Therapeuses,"  vol.  i,  p.  337. 
t  Jour.  A.  M.  A.,  Ixiv,  p.  582. 


BLOOD    TRANSFUSION    AND    INTRAMUSCULAR    INJECTION  787 

of  the  red  blood  cells  of  either  donor  or  patient  by  the  serum  of  the 
other,"  or  to  failure  to  select  donors  free  from  infectious  disease  capa- 
ble of  transmission  in  the  blood.  Preliminary  tests  are,  therefore 
always  essential  to  exclude  the  possible  occurrence  of  hemoiysis  and 
to  insure  the  absence  of  such  types  of  blood  infection  as  syphilis  and 
malaria. 

The  indications  for  transfusion  in  children  include  severe  secondary 
hemorrhages  from  whatever  cause  (whether  typhoid  fever  or  tonsil- 
lectomy), severe  secondary  anemia,  the  cause  of  which  can  be  con- 
trolled, hemorrhagic  disease  of  the  new-born,  purpura,  and  occasional 
cases  of  malnutrition  or  infectious  disease.  Intramuscular  injections 
of  blood  from  convalescent  scarlet  fever  patients  have  thus  been  em- 
ployed by  Park  and  Zingher  in  treating  severe  cases  of  this  disease  and 
with  apparent  good  results. 

In  the  actual  application  of  transfusion  in  a  child's  case,  the  external 
jugular  vein  or  the  median  basilic  is  selected  to  receive  the  blood  and 
the  amount  introduced  is  seldom  over  7  ounces. 

In  hemorrhages  of  the  newly-born  the  intra-muscular  injection  of 
blood  has  been  successful  in  absolutely  controlling  the  hemorrhage  in 
4  cases.  In  each  patient  1  ounce  of  blood  was  injected — 3^^  ounce  into 
each  buttock. 

The  advantages  of  direct  blood  injection  over  transfusion  are  con- 
siderable; the  technic,  which  consists  only  in  extracting  the  blood 
from  the  vein  of  the  donor  and  injecting  it  intra  muscularly,  can  be 
carried  out  by  any  physician.  Tests  for  agglutination  and  hemolysis 
are  not  required. 

Transfusion  has  been  used  in  a  child  who  developed  a  severe 
purpura  after  diphtheria.  There  were  extensive  hemorrhages  under 
the  skin  and  uncontrollable  bleeding  from  the  nose  and  gums.  Six 
ounces  of  blood  was  transfused  by  Lindemann,  using  his  own  method. 
The  bleeding  promptly  ceased  and  the  child  recovered.  I  am  confident 
that  the  issue  would  have  been  fatal  had  transfusion  not  been  promptly 
employed. 

A  boy  eight  years  of  age  developed  severe  influenza,  double  otitis 
media,  double  mastoid  and  sinus  thrombosis  of  the  right  side,  all  of 
which  were  operated  as  the  occasion  arose.  Recovery  was  proceeding 
slowly  and  after  three  weeks  of  a  most  exhausting  illness  lobar  pneu- 
monia developed.  It  seemed  that  recovery  was  now  impossible.  The 
parents  were  advised  that  transfusion  held  out  the  only  hope.  Two 
transfusions  were  given  by  Lindemann,  using  his  own  method,  with  an 
interval  of  two  days.  At  the  first  transfusion  8  ounces  of  blood  was 
given;  at  the  second,  6  ounces.  The  boy  is  perfectly  well  to-day,  two 
years  after  the  illness.  I  am  confident  that  recovery  would  have  been 
impossible  without  the  transfusions. 

I  have  employed  transfusion  in  8  cases  of  extreme  secondary  anemia 
in  infants  (p.  404)  with  complete  cure  in  7  cases.  One  case  showed 
no  improvement.     (For  transfusion  in  acidosis  see  p.  715.) 


788  THE    PRACTICE    OF    PEDIATRICS 

LAVAGE— STOMACH- WASHING 

To  Seibert,  of  New  York,  is  due  the  credit  of  first  calling  attention 
in  this  country  to  the  value  of  stomach-washing.  Its  use  was  soon 
appreciated  by  pediatricians  generally,  and  at  the  present  time  it  is  an 
indispensable  therapeutic  measure  with  those  who  are  actively  engaged 
in  children's  hospitals,  in  outpatient  or  in  private  work  among  children. 
In  the  vomiting  of  children,  whether  due  to  an  acute  gastro-enteric 
infection,  chronic  indigestion,  or  a  subacute  attack  of  chronic  gastritis, 
it  is  equally  valuable.  The  dangers  of  stomach-washing  can  be  said  to 
be  practically  nil.  A  colleague  a  few  years  ago,  while  washing  the 
stomach  of  a  child  two  years  of  age,  turned  away  for  a  moment,  when 
suddenly  the  struggling  child  disconnected  the  tube  from  the  glass 
connecting-rod  and  swallowed  the  tube.  Attempts  at  its  removal 
through  the  bowel  were  unsuccessful;  gastrostomy  was  performed,  the 
tube  removed,  and  the  child  recovered.  This  is  the  only  accident  of 
any  kind  I  have  ever  known  during  stomach-washing. 

The  Operation. — For  lavage,  the  child  is  easiest  handled  when  its 
arms  are  pinned  to  its  sides  by  a  towel  passing  around  the  body.  It 
may  rest  on  its  back  in  a*  crib,  or  sit  upright  on  the  lap  of  the  nurse  or 
mother  (Fig.  116).  The  clean  left  index-finger  of  the  physician  is 
placed  upon  the  base  of  the  patient's  tongue.  The  tube,  moistened 
with  the  fluid  to  be  used  in  the  washing,  not  with  oil,  is  passed  down  over 
the  base  of  the  tongue  into  the  esophagus.  Passage  of  the  tube  into 
the  larynx  is  practically  impossible.  I  have  washed  the  stomachs  of 
many  hundred  children,  and  the  introduction  of  the  tube  has  never 
been  attended  with  difficulty.  When  it  has  entered  the  esophagus,  it 
should  be  passed  rapidly  into  the  stomach.  At  least  nine  inches  of  the 
tube  will  be  required  to  reach  the  lower  portion  of  the  stomach.  At 
first  the  child  will  cough,  retch,  and  become  red  in  the  face,  but  this 
need  cause  no  alarm.  He  will  soon  cry  and  begin  to  breathe  regularly. 
When  the  tube  is  in  position,  the  funnel  should  be  held  the  length  of 
the  tube,  two  and  one-half  to  three  feet  above  the  patient's  body;  the 
water,  which  should  be  first  boiled,  may  then  be  poured  into  the  funnel. 
At  first  the  water  may  remain  stationary  in  the  funnel,  owing  to  the 
pressure  of  air  in  the  stomach  and  the  straining  of  the  child.  When 
the  child  relaxes  or  the  air  escapes,  being  forced  upward  through  the 
water,  the  water  will  pass  rapidly  into  the  stomach. 

The  apparatus  described  under  Gavage  (p.  790,  Fig.  117)  is  used. 
It  should  always  be  boiled  before  using.  If  much  mucus  is  present, 
a  1  per  cent,  solution  of  boric  acid  or  borax  may  be  used.  The  amount 
introduced  into  the  stomach  at  one  time  varies  with  the  age  of  the 
child.  For  a  baby  of  one  week  1  ounce  may  be  used;  at  six  weeks,  2 
ounces;  at  six  months,  from  4  to  6  ounces.  It  is  rarely  advisable  to 
introduce  more  than  6  ounces  at  one  time.  The  fluid  is  allowed  to  run 
into  the  stomach  and  is  then  siphoned  out  by  lowering  the  funnel,  the 
process  being  repeated  until  the  fluid  returns  perfectly  clear.  From 
one  to  two  pints  of  water  may  be  necessary  to  complete  the 
washing. 


LAVAGE STOMACH- WASHING 


789 


Indications. — It  is  rarely  necessary  to  wash  the  stomach  oftener 
than  twice  in  twenty-four  hours.  Ordinarily,  in  the  acute  vomiting 
cases,  one  washing  daily  for  four  or  five  days  will  answer.  In  cases  of 
chronic  indigestion  with  regurgitation  the  washing  will  be  needed  less 
frequently — once  a  day,  or  once  every  second  or  third  day. 

The  following  is  frequently  the  history  of  a  case  of  chronic  indiges- 
tion with  vomiting:    There  has  been,  for  several  weeks,  vomiting  of 


116. — ^Lavage. 


food  and  mucus,  two  or  three  times  daily.  The  stomach  has  been 
washed,  the  child  carefully  dieted  with  a  plain  barley-water  or  a  weak 
milk  mixture,  and  no  vomiting  has  occurred  for  perhaps  twelve,  twenty- 
four,  thirty-six,  or  forty-eight  hours,  when  the  regurgitation  or  vomit- 
ing again  commences  as  before.  In  such  a  case  it  will  soon  be  learned 
how  frequently  the  washings  should  be  repeated  in  order  to  control  the 
vomiting. 


790  THE    PRACTICE    OE    PEDIATRICS 

Illustrative  Case. — A  recent  case  represents  my  management:  A  child  six  months 
old  suffering  from  malnutrition  had  a  history  of  persistent  vomiting  after  each  feed- 
ing. A  greater  part  of  the  food  taken  was  lost.  What  was  not  vomited  was 
digested  imperfectly,  as  was  shown  by  the  stools.  The  stomach  was  washed  and  a 
large  quantity  of  thick  mucus  and  curds  removed.  The  child  was  given  a  barley- 
water  diet.  There  was  no  vomiting  for  three  feedings,  and  then  only  a  small 
quantity  of  barley-water  was  thrown  off.  After  three  days,  following  daily  wash- 
ings, the  vomiting  entirely  subsided.  The  child  was  given  a  weak  milk  mixture, 
one-fifth  milk  and  four-fifths  barley-water,  and  no  significant  vomiting  resulted. 
The  food  was  carefully  strengthened,  and  although  in  two  weeks  the  vomiting  had 
entirely  ceased,  the  washings  were  continued  at  intervals  of  two  or  three  days  for 
a  month  until  the  water  siphoned  out  was  free  from  mucus. 

In  severe  cases  of  chronic  indigestion  the  washings  at  intervals  of 
two  or  three  days  may  be  continued  with  advantage  for  several  months. 
It  must  be  remembered  that  in  these  chronic  cases  of  indigestion  the 
patient  is  ill  through  abuse  of  the  stomach — usually  because  too  strong 
food  has  been  given,  or  too  much  of  a  suitable  food  has  been  given  at 
too  frequent  intervals.  As  important,  then,  as  the  stomach-washing, 
is  the  giving  of  food  suited  to  the  child's  digestive  capacity.  Lavage 
is  of  little  service  if  the  bad  feeding  continues. 

The  field  of  usefulness  of  lavage  is  not  entirely  confined  to  vomiting 
cases.  Children  with  indifferent  appetite  and  limited  food  capacity, 
but  without  vomiting,  are  often  greatly  benefited  by  the  treatment. 
A  story  frequently  heard  in  our  consulting  room  is  as  follows :  Food  is 
taken  without  relish.  The  child  must  be  coaxed  to  eat.  There  is  loss 
of  appetite,  usually  the  result  of  improper  food  or  faulty  feeding  meth- 
ods. Some  patients  are  absolutely  indifferent  to  food;  many  refuse  it 
altogether.  In  this  class  a  stomach-washing  once  a  day  will  often  be 
followed  by  a  surprising  improvement  in  the  appetite.^  I  know  of  no 
better  appetizer  for  many  of  these  pitiful  looking  babes.  In  not  a  few 
instances  I  have  been  surprised  at  the  large  amount  of  mucus  removed 
from  the  stomach  of  one  of  these  children  in  whom  there  had  been  no 
vomiting  whatever,  which  teaches  us  that  there  may  be,  in  infants, 
stomach  disorders  of  considerable  importance  without  vomiting  or, 
in  fact,  without  any  other  symptom  than  loss  of  appetite  and 
malnutrition. 

GAVAGE 

Gavage,  or  forced  feeding,  is  the  introduction  of  nourishment  into 
a  child's  stomach  by  means  of  a  tube  (Fig.  117).  The  tubes  are  to 
be  obtained  at  the  instrument-makers  and  are  known  as  "stomach- 
tubes  for  children,"  or  the  physician  can  make  one  himself  at  a  small 
cost.  All  that  is  required  is  a  soft-rubber  catheter,  American  No.  12, 
a  ^-g  inch  glass  tube  2  inches  long,  2  feet  of  3^  inch  plain  rubber  tub- 
ing, and  a  small  glass  funnel.  An  extra  opening  should  be  cut  in  the 
catheter  about  j-i  inch  from  the  original  one.  This  allows  a  more 
rapid  introduction  of  the  nourishment.  The  opening  can  very  easily  be 
made  with  a  small  pair  of  curved  scissors. 

The  position  of  the  child  for  gavage  may  be  the  same  as  for  stomach- 
washing,  or  the  child  may  rest  on  his  back  (Fig.  118).  It  is  well  to 
clear  out  the  stomach  with  warm  water  before  each  feeding.     In  chil- 


GAVAGE 


791 


dren  without  teeth  the  bare  index-finger  is  all  that  is  necessary  to  keep 
the  mouth  open.  In  children  with  teeth  the  Denhard  gag  of  the 
O'Dwyer  intubation  set  (p.  640)  should  be  used. 

Gavage,  or  forced  feeding,  will  be  found  useful  in  three  types  of 
cases:  first,  as  a  means  of  feeding  in  obstinate  vomiting. 

In  Obstinate  Vomiting. — Several  years  ago,  when  the  writer  was 
resident  physician  at  the  New  York  Infant  Asylum,  a  series  of  observa- 
tions were  made  dn  cases  of  persistent  vomiting  which  could  not  be 
controlled  by  stomach-washing  or  the  ordinary  means  of  treatment. 
It  was  found  that  patients  who  could  not  retain  a  teaspoonful  of  water 
administered  by  a  spoon  or  a 
bottle  would  retain  from  3^^ 
ounce  to  one  ounce  of  water 
given  through  a  tube.  The 
same  child  who  vomited  one 
teaspoonful  of  milk  or  other 
food  would  retain  this  amount 
and  a  great  deal  more  when 
the  food  was  given  by  the 
tube.  This  discovery  led  to 
more  extended  observations. 
Twenty  cases  of  persistent 
vomiting  in  all  were  treated 
in  this  way,  of  which  eight- 
een were  relieved.  This 
series  of  observations  was 
the  first  made  relating  to  the 
use  of  gavage  or  forced  feed- 
ing  in   persistent   vomiting.* 

When  used  for  the  obsti- 
nate vomiting  cases,  it  is  well 
to  use  gavage  only  once  every 
four  or  six  hours,  with  from  one- 
third  to  one-half  the  quantity 
of  food  given  in  health. 

The  tube  which  is  to  be 
passed  into  the  stomach 
should  never  be  oiled,  but 
merely  dipped  into  the  solution  that  is  to  be  used.  It  is  then  passed 
in  rapidly  with  the  funnel  empty  and  the  nourishment  is  immedi- 
ately poured  into  the  funnel.  When  the  food  has  passed  into  the 
stomach,  the  tube  should  be  compressed  and  quickly  withdrawn,  as 
some  of  the  liquid  will  be  retamed  in  the  tube  if  it  is  withdrawn  slowly. 
If  this  is  done  without  compressing  the  tube,  an  escape  of  food  into  the 
larynx  may  take  place  during  the  withdrawal  of  the  tube  and  cause 
choking,  coughing,  and  perhaps  vomiting.     The  food  selected  should 

*  Kerley:  "Gavage  in  Persistent  Vomiting  in  Infants,"  Archives  of  Pediatrics, 
February,  1891. 


Fig.  117. — Stomach-tube. 


792 


THE    PRACTICE    OF    PEDIATRICS 


be  thin  dextrinized  gruels,  or  broths  and  gruels  combined,  which  have 
answered  well  in  some  cases. 

In  Severe  Illness. — In  a  severe  illness,  such  as  diphtheria,  pneumo- 
nia, and  the  grave  intestinal  diseases,  gavage  may  save  the  life  of  the 
patient.  Not  infrequently,  in  such  cases,  insufficient  nourishment  is 
taken  to  support  life.  Rectal  feeding  is  usually  of  value  only  for  a  day 
or  two,  as  children  soon  become  intolerant  of  it.  In  such  circum- 
stances, gavage  may  be  employed  advantageously  for  several  days  at 
a  time.  In  fact,  it  is  the  only  way  by  which  the  child  can  be  properly 
nourished. 


Fig.  118. — Feeding  by  gavage. 

Predigested  cereal  foods,  completely  peptonized  milk,  and  stimu- 
lants well  diluted  may  be  given.  Usually  these  patients  badly  need 
water.  If  there  is  no  tendency  to  vomiting,  a  large  quantity  of  water 
may  be  given  with  the  nourishment  selected,  so  that  they  may  receive 
as  much  Hquid  as  they  are  accustomed  to  in  health. 

In  Malnutrition,  Exhaustion,  and  Narcosis. — Gavage  is  also  most 
useful  in  cases  of  extreme  malnutrition  and  exhaustion,  or  in  alcohol  or 
opium  narcosis.     Infants  suffering  from  an  extreme  degree  of  malnutri- 


COLON    IRRIGATION  793 

tion  and  exhaustion  are  often  admitted  into  a  hospital;  and  occasion- 
ally they  are  seen  in  private  practice.  The  children  are  so  reduced  in 
strength  that  not  enough  energy  remains  for  the  taking  of  nourishment. 
In  these  cases  gavage  is  distinctly  a  life-saving  measure.  The  food 
should  be  predigested  cereals,  peptonized  milk,  or  one  of  the  various 
peptone  preparations,  given  in  quantities  suitable  to  the  age  of  the  child. 
For  a  child  four  months  of  age,  from  2  to  4  ounces  of  peptonized  milk 
may  be  given  every  two  hours.  Before  the  next  feeding  it  is  well  to 
introduce  a  few  ounces  of  water  and  withdraw  it  to  see  if  the  food  has 
been  properly  digested.  By  this  means  of  feeding  there  will  be  noticed, 
if  the  vitality  is  not  at  too  low  an  ebb  at  the  commencement,  a  daily 
increase  in  strength  and  vigor,  which  proves  that  the  powers  of  assimi- 
lation persist  after  the  desire  for  food  or  the  child's  ability  to  swallow 
it  has  passed.  This  proves  that  we  must  never  regard  such  a  case  as 
hopeless  so  long  as  the  child  is  breathing.  Time  and  again,  after  a  few 
days'  feeding  in  this  way,  the  child  will  take  the  food  from  the  bottle  or 
spoon.  Breastmilk,  if  it  can  be  obtained,  may  be  given  by  gavage  as 
successfully  as  can  predigested  cow's  milk.  The  malted  foods  on  the 
market  have  been  used  temporarily  with  advantage,  for,  while  deficient 
in  nutritive  value  for  the  well,  they  afford  sufficient  nourishment  for 
temporary  use  in  the  very  ill,  and  are  easy  of  digestion. 

Illustrative  Case. — In.  a  recent  case  seen  in  consultation,  the  patient,  three 
months  old,  was  almost  moribund,  as  the  result  of  extreme  malnutrition.  The  tem- 
perature ranged  from  94°F.  to  96°F.  for  several  days.  No  food  could  be  taken.  A 
wet-nurse  was  secured,  but  the  child  would  not  nurse.  He  was  pale,  apathetic,  and 
too  weak  to  cry.  The  wet-nurse's  milk  was  drawn  from  the  breast  and  spoon- 
feeding attempted,  but  swallowing  was  impossible.  One  and  one-half  ounces  of 
breast-milk  were  fed  by  gavage,  but  this  proved  too  strong,  and  the  child  promptly 
vomited.  The  milk  was  then  diluted  one-half  with  weak  barley-water.  At  first 
one  ounce  was  given  at  a  feeding;  then  this  was  gradually  increased  to  two  ounces, 
all  the  feedings  being  retained  and  digested.  In  a  week  the  child  was  able  to 
nurse,  and  made  a  complete  recovery,  weighing,  when  seven  months  of  age,  14 
pounds.     At  the  time  gavage  was  commenced  the  weight  was  but  5  pounds. 

COLON  IRRIGATION 

Colon  irrigation  was  brought  prominently  into  use  several  years  ago 
as  a  remedy  in  the  intestinal  summer  disorders  of  young  children. 
While  unquestionably  its  usefulness  in  this  respect  has  been  overes- 
timated and  the  irrigation  overdone,  in  selected  cases  it  is  of  great  ser- 
vice. Because  a  child  has  summer  diarrhea,  colitis,  or  anj^  disorder  of 
the  intestine,  it  does  not  follow  that  irrigation  is  indicated  or  that  he 
will  be  benefited  thereby.  A  child  who  is  having  a  passage  from  the 
bowels  every  half-hour  or  hour  is  not,  according  to  my  observation, 
a  fit  subject  for  irrigation.  The  colon  is  kept  empty  by  the  active  peri- 
stalsis, and  the  washing  will  remove  nothing  more  than  a  few  shreds  of 
mucus.  The  cases  benefited  by  irrigation  are  those  in  which  peristal- 
sis is  not  particularly  active.  When  a  child  is  running  a  temperature 
of  102°F.  and  over,  with  five  or  six  green  mucous  passages  dailj^  one 
or  two  colon  irrigations  a  day  will  unquestionably  be  of  service  in 
removing  the  offending  material  from  the  intestine. 


794 


THE    PRACTICE    OF    PEDIATRICS 


Every  year  we  see  a  few  cases  of  intestinal  infection,  particularly 
those  of  a  very  acute  type,  in  wliich  there  are  high  fever,  intense  pros- 
tration, and  infrequent  bowel  action.  Occasionally  we  see  a  case  of 
this  sort  in  which  there  is  no  movement  whatever  without  assistance. 
In  such  cases  colon  irrigation  is  of  inestimable  value,  and  may  be  used 
with  advantage  as  often  as  once  in  six  or  eight  hours.  The  washing, 
even  if  properly  conducted,  is  apt  to  be  strongly  objected  to  by  the 

patient  and  should  be  com- 
pleted as  soon  as  possible. 
Too  frequent  irrigation, 
with  strong  medicated  solu- 
tions, may  keep  up  the  mu- 
cous discharge  indefinitely. 
In  a  few  children  the  resist- 
ance with  straining  is  so 
marked  and  so  continuous 
that  irrigation  is  impossible. 
These  are  usually  children 
who,  on  account  of  the  ex- 
cessive peristalsis,  do  not  re- 
quire irrigation. 

The  irrigation  is  con- 
ducted as  follows:  Normal 
salt  solution  at  95°  F.  is 
ordinarily  used,  and  a  quart 
usually  suffices.  If  there  is 
a  great  deal  of  mucus  and 
blood,  a  1  per  cent,  tannic 
acid  solution  is  better. 
The  irrigation  should  be 
continued  until  the  solu- 
tion returns  clear.  The 
temperature  of  the  solution 
may  be  varied  with  advan- 
tage, depending  upon  the 
nature  of  the  case;  thus,  in 
cases  with  subnormal  tem- 
perature and  intense  pros- 
tration, cases  of  the  so-called 
"algid"  type,  the  solution 
at  110°F.  will  act  as  a  decided  stimulant.  It  raises  the  tempera- 
ture, improves  the  pulse  and  the  general  condition  of  the  patient.  In 
cases  with  high  fever — 105°F.  or  106°F. — a  cold  solution  answers 
better.  I  have  repeatedly  employed  a  temperature  as  low  as  70°F., 
and  have  often  found  that  an  irrigation  with  four  pints  of  water  at 
70°F.  would  reduce  the  body  temperature  three  degrees. 

For  irrigation,  a  soft-rubber  catheter,  No.  18  American,  is  best, 
for  the  reason  that  its  walls  are  stiff  and  the  tube  does  not  easily  bend 


Fig.  119. — Colon  irrigation. 


COLON   FLUSHING  795 

upon  itself,  as  is  apt  to  be  the  case  when  an  ordinary  catheter  is  used. 
Should  this  occur,  the  water  may  escape  an  inch  or  two  within  the  rec- 
tum, and  obviously  be  of  no  service.  When  the  tube,  well  lubricated, 
has  been  introduced  for  9  inches,  the  tip  will  have  passed  into  the  de- 
scending colon,  and  further  introduction  will  be  of  no  advantage. 
When  the  end  of  the  tube  is  in  the  colon,  gentle  palpation  over  the  left 
side  of  the  abdomen  will  enable  one  readily  to  locate  it.  The  tube  is 
attached  to  an  ordinary  fountain-syringe  by  passing  the  distal  end  over 
the  smallest  rectal  tip,  which  is  a  part  of  the  outfit  of  every  fountain- 
syringe.  The  bag  should  be  held  not  over  three  feet  above  the  child's 
body.  When  the  water  is  allowed  to  run,  the  buttocks  should  be 
pressed  together,  for  by  so  doing  we  hope  to  flush  the  entire  large  intes- 
tine.    If  this  can  be  done,  the  irrigation  will  be  most  efficient. 

In  this  connection  I  mention  a  beneficial  effect  of  irrigation,  of 
which  we  hear  but  little,  viz.,  the  absorption  of  a  portion  of  the  salt 
solution  by  the  intestines.  Not  a  few  of  the  intestinal  cases  have  a 
very  limited  food  capacity.  As  a  result  of  the  vomiting  and  very 
frequent  liquid  stools,  the  body  is  thoroughly  drained  of  fluids.  In 
such  cases,  after  the  washing  is  completed,  I  endeavor  to  have  the 
child  retain  as  much  as  possible  of  the  normal  salt  solution.  As  an  aid 
to  this,  the  child  should  be  placed  on  his  left  side  with  the  buttocks 
elevated  and  the  tube  introduced  well  up  into  the  descending  colon. 
The  buttocks  should  be  pressed  together  so  as  to  assist  in  retaining  the 
water  after  it  has  passed  into  the  bowel.  When  a  half  pint  or  a  pint  has 
passed  in,  the  tube  should  quickly  be  withdrawn  and  the  child  kept  for 
half  an  hour  in  a  recumbent  position  with  the  buttocks  elevated.  The 
salt  solution  will  be  best  retained  when  it  is  used  warm,  at  a  tempera- 
ture of  from  100°  to  105°F. 

COLON  FLUSHING 

Colon  flushing  consists  in  passing  into  the  descending  colon  a  con- 
siderable quantity  of  normal  salt  solution  or  bicarbonate  of  soda  solu- 
tion, '^'2  ounce  to  1  pint. 

The  measure  is  used  with  much  benefit  in  selected  cases  in  which 
but  Uttle  fluid  is  taken  by  the  natural  channel.  I  have  often  been  sur- 
prised at  the  possibilities  of  the  large  intestine  for  absorbing  fluids 
when  they  are  urgently  needed  by  the  organism. 

Illustrative  Cases. — A  boy  with  cyclic  vomiting  who  had  retained  absolutely 
nothing  given  by  mouth  for  three  days  retained  one  pint  at  the  first  colon  flushing, 
one-half  pint  more  after  six  hours,  and  another  half-pint  six  hours  later.  The  flush- 
ings were  begun  on  the  third  day  of  the  attack.  Although  the  prostration  was 
extreme,  the  prompt  improvement  in  the  general  condition  of  this  patient  was  most 
gratifying.  After  the  first  injection  the  pulse  improved,  the  apathy  disappeared, 
the  child  began  to  ask  questions  and  showed  interest  in  his  surroundings. 

A  boy  nine  years  of  age,  ill  with  scarlet  fever,  who  could  take  very  little  fluid, 
was  able  to  retain  eight  ounces  of  a  salt  solution  given  at  eight-hour  intervals  for 
three  days. 

A  child  six  months  of  age  had  retained  absolutely  nothing  in  the  stomach  for 
six  days,  because  of  an  intussusception.  When  I  saw  him  on  the  sixth  day  the 
respiration  was  superficial  and  slow.     He  was  cold  and  practically  pulseless.     The 


796  THE    PRACTICE    OF    PEDIATRICS 

second  heart-sound  could  be  heard  but  faintly  with  the  stethoscope.  The  intus- 
susception, greatly  to  my  surprise,  was  reduced  by  water  pressure  (p.  235).  Hot 
salt-water  flushings  were  at  once  begun;  the  patient  retained  twelve  ounces,  given 
at  a  temperature  of  110°F.,  and  in  a  few  minutes  there  was  a  very  perceptible  im- 
provement. With  repeated  flushings  at  six-hour  intervals  the  child  continued  to 
improve  and  made  a  perfect  recovery. 

Severe  toxic  cases  of  diphtheria  and  scarlet  fever,  in  which  but  httle 
fluid  is  taken  and  in  which  the  toxicity  of  the  blood  is  extreme,  as  shown 
by  the  stupor  and  deUrium,  are  often  much  improved  by  the  free  use  of 
colon  flushing,  which  supplies  the  water  which  the  child  needs,  but 
which  cannot  be  given  by  mouth,  or  if  given  may  not  be  retained. 

Method. — I  usually  order  the  salt  solution  given  in  quantities  of 
from  one-half  pint  to  a  pint,  depending  upon  the  age  of  the  child,  at 
intervals  of  from  six  to  eight  hours,  but  never  at  a  lower  temperature 
than  100°F. 

The  apparatus  required  is  a  small  rectal  tube  attached  to  a  foun- 
tain-syringe. 

The  flushing  is  best  given  with  the  patient  resting  on  the  left  side, 
with  the  buttocks  elevated  on  a  pillow,  the  tube,  well  oiled,  being  intro- 
duced at  least  9  inches  into  the  bowel.  The  solution  at  105°  to  110°F. 
is  allowed  to  pass  into  the  bowel,  and  the  tube  is  then  quickly  with- 
drawn. To  facilitate  the  retention  of  the  fluid  the  patient  should 
remain  on  his  side  for  one-half  hour. 

HYPODERMOCLYSIS 

Hypodermoclysis  is  one  of  the  means  employed  to  introduce  drugs 
and  fluids  into  the  body  other  than  by  the  gastro-intestinal  route.  It 
is  used  chiefly  after  hemorrhage,  in  acidosis,  in  marasmus  and  in  active 
diarrhea,  in  cases  in  which  there  has  been  excessive  loss  of  bodily 
fluids. 

In  acidosis  a  4  per  cent,  chemically  pure,  bicarbonate  of  soda  solu- 
tion is  employed,  alone  or  with  4  per  cent,  of  dextrose.  From  4  to  6 
ounces  may  be  used  at  one  time  repeated  in  ten  or  twelve  hours.  In 
marasmus  and  diarrhea  a  sterile  normal  salt  solution  is  used.  Netter 
claims  to  have  had  signally  good  results  in  marasmus  in  the  use  of 
sterile  sea  water.  The  amount  of  solution  used  varies  with  the  age 
of  the  child  or  the  object  in  view.  From  2  to  4  ounces  are  usually 
employed. 

In  using  the  bicarbonate  of  soda  after  this  fashion  there  is  some 
danger  of  producing  necrosis  of  the  tissue  at  the  site  of  the  injection. 
This,  according  to  Rowland,  may  be  obviated  by  sterilizing  the  solu- 
tion by  heat.  The  bicarbonate  is  then  changed  to  the  carbonate  and 
as  the  carbonate  is  very  irritating,  it  must  be  changed  back  to  the 
bicarbonate.  This  can  be  accomplished  by  passing  carbon  dioxide 
through  the  cold  solution  to  which  a  few  drops  of  phenolphthalein, 
have  been  added  until  it  becomes  colorless. 

That  the  danger  of  necrosis  in  using  the  chemically  pure  bicarbon- 
ate of  soda  in  sterile  water  has  been  somewhat  exaggerated  would  be 


VACCINE    THERAPY  797 

suggested  by  the  observations  of  my  associate,  Dr.  Mercer  Blanchard, 
who  used  the  4  per  cent,  solution  of  the  above  in  50  infants  at  the  N.  Y. 
Nursery  and  Child's  Hospital  with  a  local  lesion  of  but  slight  irritation 
of  very  temporary  duration. 

The  solution  is  introduced  very  slowly  by  gravity,  the  container 
being  placed  about  2  feet  above  the  child's  body. 

VACCINE  THERAPY 

Fundamental  Principles. — Vaccine  therapy  for  prevention  or  cure 
of  infection  has  for  its  object  the  production  of  an  active  immunity  to 
the  specific  bacteria  concerned,  while  serum  therapy  produces  a  passive 
immunity  only. 

Immunity,  which  is  resistance  or  lack  of  susceptibility  to  a  given 
disease  or  microorganism,  may  be  natural  or  acquired.  Artificial  or 
acquired  immunity  may  be  the  result  of  an  attack  of  the  disease  itself 
or  may  follow  inoculation  with  living  cultures  of  microorganisms  in 
sublethal  doses  or  in  an  attenuated  state  with  dead  cultures,  or  with 
those  products  of  the  growth  and  metabolism  of  bacteria  known  as 
toxins.  Immunity  so  acquired  is  active  or  direct,  comparatively  slow 
in  appearance,  and  of  comparatively  long,  though  variable,  duration. 
It  is  brought  about  by  the  development  in  the  blood-serum  of  sub- 
stances antagonistic  to  the  vital  activity  of  the  bacteria  or  to  the  toxins. 
Such  substances  are  known  as  antibodies.  The  serum  of  an  animal 
which  has  been  actively  immunized  and  which  is  rich  in  antibodies  may 
be  inoculated  into  another  animal  for  the  purpose  of  combating  infec- 
tion. The  immunity  thus  produced  in  the  second  animal  is  indirect 
or  passive  and  of  comparatively  short  duration. 

The  antibodies  are  of  several  kinds :  agglutinins,  opsonins,  bacteri- 
cidins  and  lysins.  They  are  formed  by  the  tissue-cells  under  the  stimu- 
lus of  the  infecting  bacteria,  at  first  locally,  then  generally,  and  are 
present  in  the  serum  and  to  a  lesser  extent  in  the  other  body  fluids. 
They  manifest  them.selves  in  certain  definite  ways,  demonstrable  and 
measurable  by  laboratory  methods:  agglutination  reaction,  opsonic 
index,  bactericidal  tests,  and  the  complement  deviation  test.  Clinic- 
ally, their  increase  is  accompanied  by  amelioration  of  the  symptoms  of 
infection.  The  aim  of  both  vaccine  and  serum  therapy,  then,  is  to  aid  the 
production  of  antibodies  in  order  to  effect  a  destructio7i  of  the  invading  bac- 
teria and  the  neutralization  of  their  toxins.  Metchnikoff  claimed  that 
the  destruction  of  microorganisms  is  brought  about  by  their  ingestion 
by  phagocytes,  especially  polymorphonuclear  leukocytes.  Denys  and 
Leclef  proved  that  there  is  a  substance  in  the  blood-serum  which  pre- 
pares the  bacteria  for  phagocytosis.  This  sensitizing  substance  was 
named  "opsonin"  by  Wright  and  Douglas,  who  elaborated  methods  for 
its  study  in  the  laboratory  and  for  its  practical  application  to  the  treat- 
ment of  infections  by  means  of  vaccines  made  of  suspensions  of  dead 
bacteria.. 

It  has  been  found  in  general  that  the  opsonins  are  below  normal  at 


798  THE    PRACTICE    OF    PEDIATRICS 

the  onset  of  an  infection  and  during  the  height  of  the  acute  stage,  and 
that,  as  improvement  occurs,  the  amount  of  opsonin  in  the  blood-serum 
increases.  The  administration  of  dead  cultures  of  the  bacteria  causing 
the  infection  stimulates  the  production  of  opsonins. 

The  suspension  of  bacteria  is  made  in  normal  salt  solution  from  an 
agar-culture  not  over  twenty-four  hours  old.  It  should  not  be  too 
thick,  and  should  be  free  from  clumps,  which  may  be  recovered  by  shak- 
ing or  by  manipulating  with  a  capillary  pipet. 

Capillary  pipets  of  the  same  caliber  having  been  selected,  equal 
quantities  of  the  patient's  serum,  leukocytes,  and  bacteria  are  drawn  up 
and  thoroughly  mixed  in  one,  while  normal  serum,  leukocytes,  and  bac- 
teria are  drawn  into  another.  A  control,  using  normal  salt  solution 
instead  of  serum,  should  also  be  made.  The  pipets  are  sealed  below 
and  incubated  for  fifteen  minutes  at  37°C.  The  mixture  is  then  ex- 
pelled on  a  glass  slide,  thoroughly  mixed  again,  and  spread  on  clean 
slides.  After  fixing  in  methyl-alcohol  and  staining  in  methylene-blue 
(Manson  stain  is  excellent  for  the  purpose),  the  slides  are  placed  under 
the  microscope  and  the  number  of  bacteria  contained  within  50  leuko- 
cytes is  counted.  This  gives  the  phagocytic  index.  The  quotient  of 
the  patient's  and  the  normal  phagocytic  indices  equals  the  opsonic  index 
of  the  patient.  More  satisfactory  results  have  recently  been  obtained 
by  making  the  tests  with  diluted  serum,  according  to  Neufeld.  The 
opsonins  in  the  normal  blood-serum  used  for  control  are  found  to  dis- 
appear in  a  lower  dilution  than  do  the  immune  opsonins  in  the  blood  of 
the  patient  who  has  been  immunized  by  the  disease  or  by  the  adminis- 
tration of  vaccines.     Detections  from  1  :  10,000  may  be  made. 

Preparation  of  Vaccine. — A  vaccine  is  made  by  suspending  agar- 
cultures  less  than  twenty-four  hours  old  in  normal  salt  solution.  In 
order  to  estimate  the  dose  even  approximately,  the  bacterial  suspen- 
sion is  standardized  by  counting  the  bacteria  in  relation  to  red  blood 
cells.  The  method  is  as  follows:  Equal  quantities  of  bacterial  suspen- 
sion and  of  blood  from  a  normal  person  are  drawn  into  a  capillary  pipet, 
mixed,  and  thinly  spread  on  a  slide.  The  red  cells  and  the  bacteria 
are  then  counted  in  a  number  of  fields.  Since  the  normal  blood  con- 
tains 5,000,000  red  cells  to  the  cubic  millimeter,  the  number  of  bacteria 
in  proportion  to  the  red  cells  can  be  estimated  per  cubic  millimeter, 
and  the  actual  count  per  cubic  centimeter  readily  calculated.  The 
tube  containing  the  bacterial  suspension  is  sealed  and  heated  for  one 
hour  at  58°  C.  Control  cultures  are  then  made  to  test  the  sterility  of 
the  imdiluted  suspension.  This  having  been  properly  accomplished, 
the  vaccine  is  diluted  in  bottles  or  ampules  with  sterile  normal  salt 
solution,  according  to  the  dose  desired  per  cubic  centimeter,  and  prop- 
erly sealed.  Thus,  if  the  actual  count  showed  that  5,000,000,000 
bacteria  were  present  in  a  cubic  centimeter,  diluting  the  vaccine  50 
times  by  adding  one  cubic  centimeter  of  undiluted  vaccine  to  49  c.c. 
of  sterile  salt  solution  would  make  a  vaccine  containing  100,000,000 
bacteria  in  one  cubic  centimeter.     Injections  of  one  cubic  centimeter 


VACCINE    THERAPY  799 

or  less  are  made  into  the  shoulder,  back,  or  thigh  under  strictest 
aseptic  precautions. 

Staphylococcus. — It  is  in  staphylococcus  infections  that  the  vaccine 
treatment  has  given  the  best  results.  While  it  is  always  wise  to  use  a 
vaccine  prepared  from  the  patient's  own  strain  of  staphylococcus,  it 
is  not  absolutely  essential  that  this  be  done.  Any  stock  vaccine- which 
has  given  good  results  in  a  similar  case  may  be  used,  provided  that  it 
has  been  proved  by  a  culture  made  from  the  pus  of  the  patient's  lesion 
that  staphylococci  are  the  infecting  agents.  It  is  essential  also  to  know 
whether  the  Staphylococcus  aureus  or  albus  be  present,  in  order  that 
the  appropriate  vaccine  may  be  employed.  The  dose  in  infants  under 
two  years  should  vary  from  50,000,000  to  100,000,000  of  dead  cocci. 
The  iaoculations  are  repeated  on  the  second  to  the  seventh  day  if 
necessary.  As  a  matter  of  fact,  the  test  for  the  opsonic  index  has  been 
found  to  be  too  uncertain  to  make  it  practical  and  worth  while  to  follow 
systematically ,  the  clinical  symptoms  being  sufficient  indication  of  the 
value  of  the  vaccines.  Too  rapid  or  too  large  dosage  must  be  avoided, 
because  there  is  danger  of  exhausting  the  responding  power  of  the  hu- 
man organism  by  overstimulation.  The  temperature  should  be  taken 
before  the  vaccine  is  injected,  and  every  three  hours  during  the  follow- 
ing twenty-four. 

Furunculosis  in  young  infants  has  proved  readily  amenable  to  treat- 
ment by  staphylococcus  vaccines.  Improvement  is  shown  by  a  much 
more  rapid  healing  than  usual  of  the  furuncles  already  incised,  and  by 
the  non-appearance  of  new  ones.  After  the  second  inoculation  im- 
provement is  the  rule.  The  amount  of  pus  is  lessened  and  fewer 
dressings  are  required  than  in  cases  otherwise  treated.  No  bad  effects 
from  the  injections  have  been  noted. 

In  treating  otitis  media  of  staphylococcus  origin,  vaccines  are  re- 
ported, evidently  by  enthusiasts,  as  having  proved  of  value,  also  in 
treating  suppuration  in  the  antrum,  styes,  osteomyelitis,  and  empyema. 
In  rare  and  favorable  cases  of  the  latter  disease  it  is  claimed  that  op- 
eration may  be  obviated  by  the  vaccine  injections.  After  operation 
the  vaccine  may  prove  of  real  service  in  aiding  the  more  rapid  disap- 
pearance of  pus  from  the  pleural  cavity  and  in  hastening  the  healing 
of  the  wound. 

Any  local  suppuration  due  to  staphylococci  is  rapidly  benefited  by 
vaccine  administration.  In  general  septicemia  the  results  have  been 
encouraging  (Wright).  Fifty  million  dead  bacilli  are  to  be  given  at 
the  first  injection;  this  is  followed  in  five  days  by  100,000,000  and  again 
in  five  days  by  100,000,000.  The  subsequent  administration  is  depen- 
dent upon  the  requirements  of  the  case. 

Streptococcus. — In  all  cases  of  streptococcus  inflammations  the 
results  of  vaccine  therapy  have  been  far  less  brilliant  than  in  staphj^- 
lococcus  cases,  but  still  encouraging  enough  to  warrant  their  further 
use.  It  seems  to  be  essential,  also,  far  more  than  in  the  staphylococcus 
injections,  that  the  vaccine  be  prepared  from  the  strain  of  streptococcus 
isolated  from  the  patient.     The  dose  is  about  2,000,000  to  3,500,000 


800  THE    PRACTICE    OF    PEDIATRICS 

in  babies  under  one  year  of  age,  5,000,000  to  7,000,000  between  one 
and  two  years,  10,000,000  to  30,000,000  in  older  children. 

Erysipelas. — In  erysipelas  Shorer  found  that  the  course  of  the  dis- 
ease is  apparently  shortened  by  the  inoculation  of  dead  streptococci, 
but  that  neither  migration  nor  recurrence  seem  to  be  prevented. 

Scarlet  Fever. — In  scarlet  fever  the  opsonic  index  to  streptococci 
has  been  studied  by  Tunnicliff,  who  found  that  it  is  below  the  normal 
at  the  onset  of  the  disease,  but  rises  when  the  acute  symptoms  subside. 
As  local  streptococcus  complications  appear  the  index  falls  once  more. 
Favorable  results  following  the  injections  of  dead  streptococci  in  cases 
of  scarlet  fever  have  not  been  reported.  On  the  other  hand,  this 
treatment  of  streptococcus  inflammations — like  subacute  or  chronic 
joint  affections — has  given  encouraging  results. 

Typhoid  Bacillus. — Inoculations  of  dead  typhoid  bacilli  as  a  pro- 
phylactic measure  against  typhoid  fever  have  been  extensively  em- 
ployed in  the  British,  German,  United  States,  and  Japanese  armies. 
The  most  recent  statistics  (Russell)  show  that  the  incidence  of  disease 
is  6  to  15  times  as  high  among  the  non-inoculated  as  among  the  inocu- 
lated soldiers.  Not  only  are  the  numbers  of  cases  far  less  numerous 
among  those  who  have  been  vaccinated,  but  the  clinical  course  is  much 
less  severe  and  much  shorter,  while  complications  are  fewer.  In  view 
of  these  results  prophylactic  inoculation  of  children  as  well  as  of  adults 
is  to  be  recommended  during  epidemics  of  typhoid  fever  or  before  en- 
tering a  typhoid  district.  Immunization  is  accompUshed  in  three 
vaccinations,  the  dose  of  which,  in  children,  may  be  100,000,000  to 
500,000,000  dead  baciUi. 

By  lowering  the  incidence  of  typhoid  fever  cases  antityphoid  vac- 
cination prevents  the  development  of  carriers  of  typhoid  bacilli,  and 
thus  is  fully  justified.  The  development  of  carriers  by  the  inoculation 
has  been  reported,  but  it  is  rare. 

Gonococcus. — In  vulvovaginitis  due  to  the  gonococcus  in  infants 
under  one  year  of  age,  the  injections  of  dead  gonococci  have  had  no 
effect  in  shortening  the  course  of  the  disease,  in  lessening  the  amount  of 
discharge,  nor  in  causing  the  cocci  to  disappear  from  the  vagina.  In 
older  children  Hamilton  and  Cooke  found  that  the  effect  of  the  dead 
gonococcus  injections  is  more  marked  in  chronic  than  in  acute  cases, 
the  disease  being  very  decidedly  shortened  in  its  course.  The  later 
stages  of  the  acute  cases  were  also  shortened,  while  no  result  was  noted 
in  the  first  weeks  of  the  attack.  Hamilton  and  Cooke  observed  no 
advantage  from  the  use  of  a  vaccine  made  from  the  patient's  own 
organism.  The  initial  dose  of  5,000,000  was  gradually  increased  to 
40,000,000  or  50,000,000,  according  to  the  needs  of  the  case.  Injec- 
tions at  eight-  or  nine-day  intervals  proved  best.  (For  personal  obser- 
vations see  p.  469.) 

Meningococcus. — In  cerebrospinal  meningitis  due  to  the  meningo- 
coccus of  Weichselbaum  vaccine  therapy  has  been  tried,  but  it  has  be- 
come superfluous  in  view  of  the  brilliant  results  obtained  by  means  of 
the  anti-meningococcus  serum  of  Flexner  and  Jobling. 


VACCINE    THERAPY  801 

Bacillus  Coli  Communis. — Inoculations  of  dead  colon  bacilli  in 
doses  of  10,000,000  to  50,000,000  are  reported  to  have  given  excellent 
results  in  cases  of  cystitis  and  pyelitis  due  to  that  microorganism.  The 
symptoms  are  said  to  subside  rapidly,  and  the  bacilli  to  disappear  from 
the  urine  in  a  comparatively  short  time. 

Tubercle  Bacillus. — ^Local  tuberculous  lesions  have  been  treated  by 
injections  of  tuberculin  in  very  small  doses  with  good  effect.  This  is 
true  of  chronic  local  tuberculosis  without  constitutional  symptoms, 
especially  in  bone,  joint,  gland,  skin,  and  eye  affections.  In  pulmonary 
phthisis  of  a  chronic  type,  running  a  nearly  apyretic  course,  tuberculin 
is  also  of  value.  In  all  acute  tuberculous  lesions  with  marked  fever 
and  general  symptoms  tuberculin  therapy  has  proved  useless,  and  it 
may  be  attended  by  grave  danger.  The  dose  of  crude  tuberculin,* 
administered  for  purposes  of  immunization  in  a  chronic  tuberculous 
lesion,  should  be  very  small,  3^^000  milligram,  gradually  increased  to 
3^0oo>  HooOj  01'  more.  The  inoculations  should  be  repeated  not  oftener 
than  once  in  ten  days,  at  first,  and  the  temperature  carefully  measured 
every  two  hours.  If  a  rise  occurs,  the  dose  has  been  too  large,  and  must 
be  reduced  at  the  next  injection.  In  selected  cases  of  bone  and  joint 
disease  and  also  in  adenitis,  good  results  have  followed  six  or  eight 
months  of  continued  treatment,  the  dose  being  gradually  increased 
in  amount  and  the  intervals  shortened  to  three  days. 

*  Koch's  old  tuberculin,  prepared  by  the  New  York  City  Board  of  Health. 
51 


XXI.  GYMNASTIC  THERAPEUTICS 

The  section  on  Gymnastic  Therapeutics  is  included  in  order  to 
call  the  attention  of  general  practitioners  to  the  value  of  such  work 
and  to  assist  them  in  applying  necessary  treatment.  Exercises  are 
most  often  used  therapeutically  for  children  in  the  treatment  of  the 
following  conditions :  Flattened  or  narrowed  thorax,  kjrphosis,  scoliosis, 
flat-foot,  congenital  ataxias,  and  acute  anterior  poliomyelitis;  also  in 
cases  of  habitual  constipation,  malnutrition,  etc. 

The  following  pages  contain  a  description  of  the  methods  which 
have  been  carried  out  most  successfully  with  my  patients  by  Dr.  Hugh 
Currie  Thompson,  of  New  York,  to  whose  patience  and  skill  I  am  in- 
debted for  the  recovery  of  many  cases,  some  of  which  had  resisted 
other  methods  of  treatment. 

The  family  physician  has  an  opportunity  of  seeing  these  conditions 
at  a  much  earlier  stage  than  has  the  specialist,  and  at  a  time  when  they 
may  be  more  easily  corrected  than  in  later  life.  When  discovered,  such 
conditions  should  never  be  neglected  with  the  idea  that  in  time  the  child 
will  outgrow  them.  Such  a  belief  is  often  fallacious,  for  unless  properly 
treated,  they  are  apt  to  become  permanent.  The  necessity  for  the  cor- 
rection of  physical  defects  in  children  is  readily  appreciated  by  parents. 
Certain  principles  or  rules  are  involved  in  every  form  of  practice.  The 
following  principles  are  generally  applicable  in  gymnastic  therapeutics. 

RULES 

I.  Examination. — As  far  as  possible,  obtain  a  complete  history  of 
the  case.  Make  both  a  general  and  a  detailed  physical  examination; 
under  the  latter,  note  the  musculature,  condition  of  the  skin,  posture, 
any  deviation  of  the  spine,  position  of  thorax  and  scapulae,  side  lines  of 
body,  compare  length  of  limbs,  note  the  condition  of  the  feet.  It  is 
often  advantageous  to  take  the  height  and  weight  and  certain  measure- 
ments, such  as  girth  of  neck,  chest,  and  waist,  and  depth  of  chest  and 
abdomen.  In  cases  where  the  nervous  system  is  especially  involved, 
apply  the  tests  usually  made  in  such  cases. 

II.  Conditions  Under  Which  Exercise  Should  be  Taken. — Temper- 
ature of  Exercise-room. — The  temperature  of  the  room  should  be  from 
70°  to  75°  F.,  depending  upon  whether  or  not  the  patient  is  dressed. 
There  should  be  no  draft  upon  the  patient.  Therapeutic  gymnastics 
involves  fewer  groups  of  muscles  than  ordinary  gymnastic  work  and 
the  execution  is  slower.  The  general  circulation  and  respiration  are 
not  stimulated  as  much,  and,  therefore,  the  heat-production  is  less. 

Clothing. — In  the  beginning,  the  parts  of  the  body  involved  in  the 
exercises  should  be  devoid  of  clothing.     A  single  thickness  of  clothing 

803 


804  THE  PRACTICE  OF  PEDIATRICS 

may  mislead  as  to  the  corrective  effect  obtained.  At  frequent  intervals, 
at  least  once  a  week,  the  child  should  be  uncovered  for  the  purpose  of 
observation  during  exercises.  It  is  sometimes  desirable  to  have  the  cloth- 
ing removed  during  each  treatment.  At  all  times  a  child's  clothing 
should  be  simple  and  hygienic,  permitting  unhampered  movements. 

Double  Mirrors,  Etc. — The  use  of  double  mirrors  and  a  stringed 
screen  are  sometimes  desirable  so  that  the  child  may  see  when  he  has 
a  correct  position. 

m.  Frequency  and  Duration  of  Treatments. — ^Treatment  should 
be  given  either  for  a  half-hour  or  an  hour,  three  times  a  week,  or  a  half- 
hour  or  an  hour  daily  (Sundays  and  holidays  excepted),  the  arrangement 
being  dependent  upon  the  needs  of  the  case  and  the  physical  condition 
of  the  patient.  The  above  is  not  too  often  if  the  following  points  are 
considered : 

(a)  The  length  of  time  during  which  the  condition  has  been  developing. 

(6)  The  number  of  waking  hours  intervening  between  treatments 
when  faulty  postures  are  apt  to  be  maintained. 

(c)  That  progress  should  be  made  as  rapidly  as  possible,  so  that 
the  changed  structure  may  be  the  basis  for  the  period  of  growth. 

Many  times  this  rule  must  be  modified,  owing  to  the  physician's 
lack  of  time  and  the  expense  to  the  patient's  family.  Instead  of  an  hour's 
supervision  daily,  it  may  mean  supervision  by  the  physician  only  once 
every  two  weeks,  supplemented  by  careful  home  supervision  fifteen 
minutes  daily.  This  should  be  the  minimum  of  attention  given  to  any 
case. 

rV.  Prescription  of  Exercises. — Forms  of  Exercise. — No  certain  sys- 
tem of  exercises  need  be  followed  as  long  as  the  exercises  used  have 
an  anatomic  and  physiologic  basis.  Both  active  and  passive  move- 
ments are  used  with  and  without  resistance.  Exercises  with  resistance 
given  by  the  physician  are  used  much  in  corrective  work,  for  in  this 
form  of  exercise  the  physician  can  easily  judge  as  to  the  amount  of  ex- 
ertion, and  increase  or  decrease  it  at  will,  and  the  physician  should  re- 
member that  in  most  cases  the  stretching  of  the  contracted  muscles  is 
quite  as  important  as  the  strengthening  of  the  weak  and  overstretched 
muscles.  In  cases  of  paralysis,  injury,  kyphosis,  and  scoUosis,  where 
the  weak  muscles  need  treatment  to  restore  their  normal  strength,  the 
antagonistic  muscles  which  are  contracted  and  shortened  should  be 
stretched  at  every  treatment  (even  though  tenotomy  has  been  per- 
formed) until  the  weak  groups  have  regained  their  normal  tone. 

Accuracy  of  Execution. — Accuracy  of  execution  of  each  and  every 
exercise  given  in  the  prescription  is  essential.  A  possible  exception 
to  this  might  occur  in  the  treatment  of  such  cases  as  malnutrition  or 
constipation,  where  exercise  per  se  is  the  essential  thing,  but  even  in 
these  cases  conditions  may  be  such  that  very  careful  work  is  necessary. 
A  prescription  of  exercise  in  itself  means  little.  The  manner  in  which 
it  is  executed  may  actually  aggravate  the  condition,  as  the  wrong  muscles 
may  be  made  stronger  by  a  faulty  manner  of  execution.  In  writing 
out  a  prescription  of  exercise  the  physician  should  be  guided  by  the 


RULES  805 

patient's  capability  for  fairly  accurate  execution  of  each  exercise.  This 
cannot  be  gaged  by  the  physical  examination  alone,  but  the  examination 
must  be  supplemented  by  having  the  patient  try  the  exercise  for  one  or 
more  days.  Unless  he  can  approximate  the  proper  execution  without 
assuming  faulty  positions  or  postures  and  without  causing  too  much 
nerve  and  muscle  fatigue,  simpler  exercises  should  be  used.  As  the  pa- 
tient improves  or  becomes  stronger,  more  difficult  exercises  should  be 
given.     In  advancing,  the  rule  regarding  accuracy  should  be  observed. 

Exercises  have  several  details  which  need  to  be  watched  in  order 
to  secure  accurate  execution.  At  first  do  not  confuse  the  child  by  re- 
quiring absolute  accuracy  as  to  every  detail;  rather  select  one  or  two 
of  the  more  important  ones  and  insist  upon  the  most  rigid  observance 
of  these.  As  the  child  grasps  and  retains  these  ideas  and  is  able  to  carry 
them  out,  require  more,  until  all  are  mastered. 

Concentration. — Frequent  repetition  of  the  exercises  is  necessary  to 
obtain  desired  results.  In  repeating  an  exercise  many  times,  a  child  easily 
forms  the  habit  of  executing  it  with  but  httle  effort,  which  will  soon 
result  in  inattention  and  carelessness.  When  this  occurs,  bring  about 
an  increase  of  exertion  on  his  part  by  insisting  that  every  detail  be 
mastered,  or  change  to  more  difficult  exercises. 

Overwork. — If  a  child  is  fatigued  at  the  end  of  an  hour's  rest  follow- 
mg  the  treatment,  he  has  been  overworked,  and  the  exercises  should  be 
made  less  difficult.  A  certain  amount  of  muscle  soreness  must  be 
expected  during  the  first  few  days  of  work. 

The  patient  may  be  weak  and  anemic.  This  should  be  borne  in 
mind  when  the  amount  of  exercise  is  increased.  There  should  be  less 
school  work  or  play  to  insure  sufficient  rest  and  recuperation  after  the 
treatment.  If  that  is  not  possible,  the  amount  of  exercise  should  be 
increased  very  gradually.  Otherwise,  overfatigue  may  result  from  the 
carrying-out  of  exercise  excellent  in  other  respects. 

Rest. — In  many  cases  the  child  should  rest  in  a  recumbent  posture 
for  half  an  hour  after  the  treatment,  and  in  nervous  cases  the  treatment 
should  be  preceded  by  a  half-hour's  rest. 

General  Health. — ^Attention  should  be  given  to  everything  that  will 
build  up  the  general  health  of  the  patient,  such  as  bathing,  sleep,  fresh 
air,  general  exercise,  diet,  and  dress.  Suitable  furniture  (chairs,  tables, 
or  desks,  etc.)  should  also  be  considered.  Attention  to  these  things 
will  sometimes  shorten  the  time  of  treatment  by  ehminating  causative 
factors. 

Temporary  Discontinuance  or  Modification  of  Exercises. — When 
the  child  feels  indisposed,  or  there  is  an  acute  illness  of  an  apparently 
simple  character,  the  temperature  should  be  taken.  If  fever  is  present, 
exercise  should  be  omitted  until  the  nature  and  seriousness  of  the  illness 
are  known .  If  there  is  no  fever,  the  amount  of  exercise  should  be  modi- 
fied by  providing  one-half  or  one-third  of  the  amount  which  other^^^se 
would  have  been  given,  or  the  same  amount  of  time  with  movements 
which  require  less  exertion. 

When  a  child  having  a  lithemic  diathesis,  with  predisposition  to  ca- 


806  THE    PEACTICE    OF   PEDIATRICS 

tarrhal  conditions  of  the  throat  and  bronchial  tubes,  is  suffering  from  an 
acute  cold,  the  exercises  should  be  temporarily  discontinued,  or  the 
amount  of  exercise  reduced  to  one-third.  If  this  precaution  is  not  ob- 
served, a  cardiac  strain  may  result,  such  as  sometimes  follows  play  or 
exercise  in  one  who  has  had  acute  rheumatism. 

V.  Adaptation  of  Exercise  to  Practical  Ends. — ^Adapt  corrective 
positions  to  all  practical  ends:  walking,  sitting,  working,  or  playing. 

VI.  Cooperation. — Endeavor  to  secure  the  cooperation  of  mem- 
bers of  the  household,  teachers,  or  servants  between  exercise  periods 
in  order  that  the  progress  of  the  child  may  be  as  rapid  as  possible.  A 
child  is  not  at  first  capable  of  adapting  the  work  to  practical  ends  with- 
out careful  oversight  by  elders. 

There  are  two  objects  in  treatment:  One  which  should  always  be 
obtained,  that  of  improvement;  and  the  other,  complete  and  per- 
manent correction,  which  should  be  the  aim  until  an  insurmountable  ob- 
stacle is  reached.  To  gain  these  are  required  continuous  and  conscien- 
tious work,  and  the  cooperation  of  those  in  charge  of  the  child  and  of 
the  child  himself.  As  a  rule,  these  objects  cannot  be  obtained  in  a  short 
period  of  time. 

After  the  treatment  has  been  completed  the  child  should  be  brought 
for  examination  every  three  months. 

POSTURE  AND  BREATHING 

Posture  and  breathing  will  first  be  considered,  as  they  hold  an  im- 
portant place  in  the  correction  of  the  conditions  about  to  be  considered. 
A  good  posture  should  be  maintained  during  all  exercises.  Between 
treatments  the  child  should  maintain  as  good  posture  as  his  condition 
will  permit.  Telling  him  to  do  this  is  not  sufficient:  he  should  be 
given  exercises  which  will  strengthen  the  weakened  and  overstretched 
muscles  and  stretch  the  contracted  ones,  and  thus  enable  him  to  assume 
an  improved  posture.  The  work  for  correcting  posture  should  be  taken 
up  gradually.  Have  a  child  hold  a  good  posture  for  short  periods  of 
time,  beginning  with  one  minute  and  working  up  to  fifteen  minutes. 
The  child  should  be  taught  to  assume  and  maintain  a  good  posture  dur- 
ing the  entire  day,  no  matter  what  he  is  doing,  whether  at  work  or  play. 
In  the  standing  posture  the  weight  of  the  body  should  be  brought  for- 
ward until  it  rests  over  the  balls  of  the  feet  or  over  a  point  midway  be- 
tween the  toes  and  the  heels.  In  sitting,  the  weight  of  the  body  should 
be  carried  over  the  posterior  third  of  the  thighs. 

For  general  posture,  my  rule  consists  of  the  following  steps:  Heels 
together,  or  approximately  so;  knees  well  stretched;  chest  raised  high; 
head  erect  with  chin  in  (stretch  up  entire  body  as  high  as  possible) ; 
poise  weight  forward  over  balls  of  feet;  bring  shoulders  back  and  down. 
The  feet  should  be  turned  outward  slightly  or  kept  straight.  (See  Fig. 
120.) 

In  the  above  rule  do  not  relax  any  previous  step  as  a  new  one  is  taken. 
In  sitting,  insist  that  the  hips  be  pushed  well  back  in  order  that  the  child 


POSTURE   AND    BREATHING 


807 


may  not  slide  forward  so  as  to  bring  the  weight  of  the  body  over  the 
lower  spine. 

From  the  beginning,  an  attempt  should  be  made  to  improve  the 
posture.  Take  the  essential  details  for  the  child  to  follow  and  in- 
crease the  requirements  as  fast  as  practicable.  These  individual  details 
have  been  tersely  expressed  in  different  ways,  and  one  expression  may 
convey  the  idea  of  the  detail  more  clearly  to  one  patient  and  another 
expression  to  another.  For  instance:  "Chest 
Up!"  may  mean  that  you  wish  the  child,  if  he 
has  relaxed,  to  take  the  best  possible  posture  of 
the  thorax.  In  taking  a  good  position  of  the 
thorax,  there  should  be  no  raising  of  the 
shoulders,  no  conscious  taking  in  or  holding  of 
the  breath,  and  the  trunk  should  not  be  inclined 
backward,  nor  the  pelvis  or  abdomen  permitted 
to  project  forward. 

General  Considerations. — 1.  When  children 
use  bicycles,  velocipedes,  mail  wagons,  etc., 
where  they  propel  themselves  by  pedaling,  they 
should  not  ride  with  head  and  shoulders  forward 
and  chest  contracted  to  gain  advantage  and 
leverage,  but  should  have  the  body  inclined 
forward  from  the  hips,  back  straight,  and  chest 
expanded. 

2.  Improper  and  insufficient  diet,  poor  as- 
similation, lack  of  fresh  air,  and  disturbed  sleep 
cause  a  loss  of  general  tone,  which  tends  to  make 
a  child  relax  and  assume  bad  postures.  All 
these  matters  should  receive  attention.  (See 
Tardy  Malnutrition,  p.  100.) 

3.  Clothing  should  be  examined  to  see  that 
it  causes  no  pressure  or  tension.  All  garments 
should  be  loose  and  simple.  The  underclothing 
should  be  elastic  and  light  in  weight.  The  stock- 
ings should  fit  the  feet  and  should  be  supported 
by  soft  elastics  extending  from  V-shaped  pieces 
at  the  side  of  the  waist,  which  catch  the  stock- 
ings on  the  outside  of  the  legs.  The  shoes  should 
have  flexible  soles,  a  fairly  straight  line  on  the 
inside,  a  low  broad  heel,  and  should  be  broad 
enough  to  permit  the  toes  to  spread.  So  much 
depends  upon  the  condition  of  the  feet,  both 

in  standing  and  walking,  that  they  should  receive  as  careful  daily 
attention  as  the  hands.  Hats  should  first  be  for  protection.  They 
should  be  light  in  weight  and  should  come  far  enough  forward  to  pro- 
tect the  eyes  from  the  sun,  and  should  never  be  worn  far  enough  back 
to  make  the  child  tilt  his  head  to  balance  the  weight,  or  to  make  him 
bend  it  forward  to  protect  his  eyes  from  the  sun.     Outside  wraps  should 


Fig.  120. — General  pos- 
ture. 


808 


THE    PRACTICE    OF    PEDIATRICS 


be  sufficiently  light  in  weight  and  flexible  enough  to  permit  free  move- 
ment in  walking  or  running. 

4.  Sleep. — ^A  child  should  not  form  the  habit  of  sleeping  always  on 
one  side  with  the  knees  drawn  up  to  the  chest,  but  change  from  side  to 
side.  If  the  posture  is  very  poor,  he  should  for  some  time  sleep  on  the 
back  with  limbs  extended,  and  without  a  pillow.  The  mattress  should 
be  thin  and  firm,  and  the  child's  covering  light  in  weight,  and  only  a 
small  pillow  used. 

5.  Furniture.— The  furniture  a  child  uses,  especially  his  chairs,  tables, 
or  desks,  should  be  adapted  to  his  age  and  height.  Furniture  not  prop- 
erly adapted  to  children  is  one  of  the  main  causes  of  bad  posture.  Chairs 
should  have  the  height  of  seat  correspond  to  the  length  of  the  lower  leg. 


Fig.  121.- 


-  Adjustable  table,  Dr.  Mosher's  chairs,  board,  ladder,  and  blocks  for  ataxic 
exercises. 


The  child's  feet  should  rest  comfortably  upon  the  floor,  and  there  should 
be  no  pressure  under  the  knee.  The  depth  of  the  seat  should  be  no 
more  than  the  length  of  the  thigh.  If  it  is  greater,  the  child  tends  to 
slide  forward  and  assume  a  bad  posture  with  the  weight  of  the  trunk 
over  the  lower  spine.  The  back  of  a  chair  should  not  have  upright 
spindles,  but  cross-pieces,  or,  at  least,  one  cross-piece  sufficiently  high 
above  the  seat  to  allow  the  fleshy  part  of  the  hips  to  project  underneath 
it  in  order  to  bring  back  the  tuberosities  of  the  ischia  far  enough  to  sup- 
port the  weight  of  the  trunk  in  a  good  position.  The  lower  cross-bar, 
preferably  adjustable,  should  support  the  back  at  the  junction  of  the 
dorsal  and  lumbar  vertebrae.  In  addition  there  should  be  another  cross- 
bar to  support  the  upper  back. 

Dr.  Mosher's  kindergarten  chair,  sold  by  The  Milton  Bradley  Com- 


POSTURE  AND  BREATHING  809 

pany,  11  East  16th  Street,  New  York  city,  is  the  best  chair  for  children 
that  has  come  to  my  attention.  It  is  constructed  in  three  sizes,  with 
seats  ten,  twelve,  or  fourteen  inches  in  height,  but  there  is  no  lower  cross- 
bar for  the  support  of  the  back.  If  the  seat  of  a  chair  is  hollowed  out, 
there  should  be  no  raised  border  at  the  back,  as  it  would  prevent  the 
hips  from  being  pushed  well  back.  If  well-constructed  chairs  cannot  be 
obtained,  ordinary  chairs  may  be  modified  for  use  in  the  nursery  or  for 
older  children,  by  selecting  those  having  a  cross-bar  several  inches  from 
the  seat  and  sawing  the  legs  off.  If  the  seat  proves  too  deep,  a  pillow 
may  be  placed  between  the  child's  back  and  the  back  of  the  chair,  but 
should  not  extend  below  the  waist-line.     It  may  be  held  in  place  by  tapes. 

6.  Heredity. — Parents  often  attribute  a  bad  posture  with  flat  chests 
or  other  physical  deformities  to  heredity,  saying  that  a  child  "takes 
after"  one  parent  or  the  other.  Heredity  is  usually  only  a  slight  factor, 
i.  e.,  the  child  may  inherit  a  frame  or  general  constitution  or  certain 
mental  and  physical  characteristics  resembling  those  of  a  parent,  but 
the  faulty  posture,  flat  chest,  etc.,  are  in  most,  if  not  all,  cases  acquired. 
A  well-nourished  infant  has  a  straight  back.  In  a  well  child,  one  seldom 
sees  a  flat  chest  before  the  age  of  three  years. 

7.  In  very  young  children  the  deformity  is  often  induced  by  the 
position  assumed  in  play.  For  instance,  the  sitting  position  on  floor 
or  bed,  with  legs  extended  and  spine  bent  forward,  which  most  young 
children  assume  in  playing,  keeps  the  chest  in  a  bad  position  for  long 
periods  of  time  day  after  day.  This  is  especially  true  if,  for  any  reason, 
the  back  muscles  are  not  as  strong  as  usual  and  cannot  easily  maintain 
the  weight  of  the  trunk  in  an  erect  position.  For  children  who  are  kept 
in  bed  when  not  seriously  ill,  a  folded  blanket  or  air-cushion  may  be 
used  as  a  seat,  and  a  bed-table  or  tray  for  playthings  and  meals.  A  sup- 
port may  be  used  for  the  back  if  needed. 

Fig.  121  shows  Dr.  Mosher's  chair  and  an  adjustable  table,  which 
may  be  made  for  use  in  the  nursery.  The  top  of  the  table,  23^2  by  4 
feet  (or  3  by  5),  is  made  of  well-seasoned  boards,  3^  inch  in  thickness. 
These  boards  are  held  together  by  quarter-inch  pegs  and  holes,  as  are 
the  leaves  of  an  extension  dining-table.  Two  sets  of  light-weight  wooden 
horses  (legs  ^  by  2  inches  and  cross-pieces  1  by  23^^  inches)  are  used 
for  supports:  one  set,  for  use  when  the  child  is  seated,  14  to  18  inches  in 
height;  the  other,  for  use  when  standing,  24  to  30  inches  in  height.  If 
desired,  the  whole  may  be  painted  white  or  stained  and  varnished.  For 
reading  there  should  be  a  book-support  for  the  child's  books,  so  that  he 
may  keep  his  head  erect. 

8.  School  Hygiene. — Physicians  as  well  as  parents  should  interest 
themselves  in  school  conditions,  as  often  it  is  in  school  that  the  child 
contracts  bad  postures,  because  of  the  long  hours  of  confinement,  un- 
suitable desks  and  seats,  and  frequently  by  a  lack  of  proper  ventilation. 

Exercises. — The  following  exercises  may  be  used  for  correcting  bad 
posture : 

1.  The  child  stands  with  toes  from  2  to  4  inches  from  a  flat,  perpen- 
dicular surface,  as  a  closed  door.     Let  him  assume  a  good  standing 


810 


THE    PRACTICE    OF    PEDIATRICS 


position;  sway  the  body  forward  from  the  heels  (heels  kept  on  floor) 
until  the  chest  touches  the  door;  but  neither  the  abdomen  nor  head 
should  touch  it.     (See  Fig.  122.) 

2.  Raise  arms  sideways  to  shoulder  height;  lift  heels;  stretch  up 
with  head  and  chest,  in  with  chin,  and  out  with  arms. 

3.  The  child  lies  on  his  back  on  a  fairly  hard,  fiat  surface.     Place 


Fig.    122. — Posture   exercise. 


Chest   raising   against   a  flat,   perpendicular 
surface. 


your  hands  under  his  head,  raising  it  an  inch  or  two.  He  then,  re- 
clining as  before,  arches  his  body  from  head  to  heels.  (See  Fig.  123.) 
The  knees  should  be  kept  straight.  In  the  beginning,  as  in  figure,  he 
may  aid  himself  with  his  hands  in  arching  body.  Later  the  arms  should 
be  folded  lightly  on  the  chest. 


POSTURE   AND    BREATHING  811 

4.  The  child  standing,  should  raise  arms  sideways,  turn  palms  up 
at  shoulder  height,  and  continue  to  raise  them  until  the  hands  are  mid- 
way between  horizontal  and  vertical;  sway  body  forward;  stretch  up 
with  chest  and  head,  in  with  chin,  and  out  and  up  with  finger-tips. 

5.  Clasp  hands,  back  of  head.  Raise  chest  well  and  press  head 
backward,  chin  in,  resisting  with  hands.     Keep  elbows  well  back. 

Walking  Movements. — Have  patient  walk  on  balls  of  feet,  ^^'ith  arms 
extended  sideways,  shoulder  high,  maintaining  a  good  posture.  ^^Htien 
capable  of  doing  this  satisfactorily,  repeat  with  arms  raised  over  head; 
arms  should  be  well  stretched,  fingers  straight,  palms  facing  and  sepa- 
rated by  the  breadth  of  the  shoulders. 

Shot-bag  Exercises. — A  flat  circular  bag,  5  or  6  inches  in  diameter. 
The  bag  should  hold  from  3^  to  2  pounds  of  shot,  according  to  the 
strength  of  the  child.  With  the  child's  back  straight  and  chest  expanded, 
head  erect  and  chin  close  to  neck,  have  him  balance  the  shot-bag  on 


Fig.  123. — Posture  exercise.     Arching  body. 

top  of  his  head :  balance  while  sitting  or  standing  from  one  minute  up  to 
thirty  minutes ;  balance  while  rising  from  a  sitting  to  a  standing  position 
from  5  to  50  times ;  balance  while  walking  forward  and  backward  across 
the  room  from  5  to  20  times;  balance  while  walking  on  the  toes  across 
the  room  forward  and  backward  from  5  to  20  times;  balance  the  bag 
on  the  head  while  being  read  to;  balance  while  taking  the  out-of-door 
walk  for  varying  distances  from  100  feet  to  3^  mile;  balance  while  run- 
ning in  an  easy  manner. 

Static  Exercises. — Exercises  of  Position. — Simply  teUing  a  child  to 
think,  himself,  to  keep  a  good  posture,  presents  the  matter  to  him  only 
in  the  abstract,  and  involves  a  mental  strain.     He  must  be  given  certain 


812  THE    PRACTICE    OF   PEDIATRICS 

things  to  do.  The  static  exercise  reduces  the  instruction  to  the  concrete, 
and  there  is  usually  some  responsive  cooperation  from  the  child.  The 
use  of  the  static  exercises  makes  a  good  posture  possible  for  the  child, 
and  they  serve  as  an  introduction  to  a  habit  of  improved  posture.  The 
static  exercises  should  be  used  in  connection  with  the  developing  exer- 
cises, but  only  one  set  should  be  taken  up  at  one  time,  to  be  continued 
from  one  to  three  weeks,  and  then  another  set  taken  up  as  conditions 
seem  to  require. 

Illustrative  Case. — The  brother  of  a  Uttle  patient  was  a  persistent  mouth-breather. 
Some  months  previous  both  tonsils  and  adenoids  had  been  removed.  The  habit  of 
mouth-breathing  persisted,  although  its  causes  had  been  ehminated.  I  suggested 
that  the  mouth  be  kept  closed,  and  that  breathing  through  the  nostrils  be  made  an 
exercise,  beginning  with  a  minute  on  the  first  day  and  increasing  a  minute  or  two 
each  day  until  the  child  could  continue  to  breathe  with  closed  lips  for  an  hour.  He 
was  read  to  while  doing  this.  He  was  urged  to  think  of  holding  the  lips  closed  at 
other  times.  He  soon  overcame  the  habit  of  mouth-breathing.  This  illustra- 
tion shows  that  habit  must  be  reckoned  with — the  removal  of  the  cause  does  not  alone 
suffice. 

The  following  static  exercises  may  be  used  with  advantage  to  aid 
in  the  correction  of  bad  posture : 

Lying  on  Couch  or  Bed  in  Good  Position. — Have  patient  take  such 
position  from  one  to  ten  times  daily  in  order  that  he  may  learn  to  assume 
a  good  position  whenever  he  takes  a  lying  posture.  The  last  time  he 
should  remain  in  a  correct  lying  posture  from  five  to  twenty  minutes. 

Correct  Sitting.- — Have  patient  assume  a  correct  sitting  posture, 
beginning  with  a  minute,  once,  twice,  or  three  times  in  each  school  ses- 
sion, at  each  meal,  during  each  study  or  reading  period  at  home.  Grad- 
ually increase  the  time  until  the  child  is  holding  a  good  sitting  position 
from  five  to  fifteen  minutes  during  the  above  suggested  period. 

Correct  Standing. — (a)  Have  patient  rise  from  correct  sitting  to  a 
correct  standing  position  from  four  to  ten  times.  (6)  Have  child  when 
spoken  to  take  good  standing  posture  before  replying.  Often  a  child 
assumes  his  worst  standing  posture  when  spoken  to,  his  mind  being  in- 
tent upon  what  is  said  to  him,  and  he  relapses  into  the  original  poor 
posture,  (c)  Have  child  hold  good  posture  for  from  two  to  five  minutes 
while  conversation  is  carried  on. 

Similar  ideas  may  be  carried  out  while  walking,  running,  skating, 
dancing,  etc. 

BREATHING 

The  primary  object  of  breathing  is  to  aerate  the  blood  by  carrying 
oxygen  to  it  by  the  air  that  enters  the  lungs;  secondarily,  through  the 
practice  of  deep  breathing,  the  accessory  muscles  of  respiration  are  de- 
veloped, the  breadth  and  depth  of  chest  and  the  lung  capacity  are  in- 
creased. In  deep  respiration  the  amount  of  air  taken  in  is  several  times 
that  inhaled  in  ordinary  respiration.  The  amount  inhaled  in  ''tidal" 
respiration  by  an  adult  is  30  cubic  inches,  while  that  which  can  be  taken 
in  by  forced  inspiration  is  from  150  to  300  cubic  inches.  Daily  practice 
of  deep  breathing  in  the  open  air  helps  to  increase  the  resistance  of  the 
lungs  to  diseases  to  which  they  are  liable. 


BREATHING  813 

A  mistake  is  sometimes  made  in  overdeveloping  the  chest  muscles, 
so  that  the  chest  becomes  to  a  certain  extent  "muscle-bound,"  and  the 
expansion  is  lessened,  instead  of  increased.  There  is  little  danger  of 
this  when  the  development  comes  from  taking  deep  inspirations  rather 
than  by  muscular  activity  alone.  While  a  development  of  the  chest 
muscles  is  desirable,  they  should  not  be  developed  at  the  expense  of  the 
normal  expansion  of  the  "respiratory  chest."  The  aim  should  be  to 
improve  the  mobility  of  the  chest  and  the  lung  capacity  as  well  as  to 
strengthen  the  muscles. 

Two  kinds  of  breathing  are  usually  spoken  of:  thoracic  and  abdominal. 
Breathing  should  be  considered  as  a  whole,  unless  one  form  is  especially 
lacking,  as,  for  instance,  where  a  child  has  a  very  flat  chest  in  which 
diaphragmatic  or  abdominal  breathing  greatly  predominates  over  the 
thoracic,  and  there  is  Uttle  mobility  in  the  upper  part  of  the  chest.  If 
the  abdominal  breathing  needs  to  be  developed,  have  the  child  stand  in 
a  good  posture,  with  hands  placed  hghtly  over  the  lower  ribs,  with  tips 
of  the  fingers  two  or  three  inches  from  the  median  line,  and  take  long, 
deep  breaths  until  he  secures  a  good  movement  of  the  lower  ribs.  The 
hands  are  placed  over  the  ribs  only  for  the  purpose  of  feeling  the  move- 
ment. 

All  breathing  exercises  should  be  taken  with  the  body  in  a  good  po- 
sition and  may  be  done  while  standing,  lying,  sitting,  or  slowly  walking. 
Ordinarily  they  are  taken  in  a  standing  position.  If  the  muscles  are 
weak  or  if  it  is  difficult  to  stand  in  a  good  position,  the  exercises  may  be 
taken  in  a  sitting  or  reclining  position.  When  the  breathing  exercise 
is  taken  reclining,  a  couch  or  a  board  resting  on  two  chairs  may  be  used 
in  preference  to  a  bed  or  the  floor.  A  small  hard  pillow  or  a  folded  bath- 
towel  may  be  placed  under  the  shoulders  and  upper  back,  but  should 
not  extend  under  the  head.  Such  a  pad  is  used  with  advantage  in  cases 
of  kyphosis  and  lordosis. 

It  is  better  to  take  the  deep  breathing  exercises  in  the  open  air,  on 
the  highest  elevation  in  a  nearby  park,  or  during  the  daily  outing,  or 
even  while  walking  to  and  from  school  or  while  driving.  However,  one 
must  adapt  himself  to  existing  conditions,  and  at  home  the  exercises 
may  be  taken  on  a  piazza  or  balcony,  or  even  indoors,  with  wide-open 
windows,  but  the  air  should  be  as  free  from  dust  as  possible.  If  the 
windows  are  open  in  winter,  the  child  should  wear  extra  wraps  or 
clothing. 

A  breathing  exercise  should  be  preceded  by  a  number  of  strong, 
sharp  exhalations  through  the  mouth  in  order  to  empty  the  lungs  as 
thoroughly  as  possible  of  residual  air,  so  that  the  deep  inspirations  may 
fill  the  limgs  ^vith  fresh,  pure  air. 

The  clothing  should  always  be  loose,  with  no  constrictions  at  neck 
or  waist. 

Holding  the  breath  at  the  end  of  full  inspirations  may  be  done  to 
advantage,  if  it  is  not  held  longer  than  five  seconds.  Retaining  the  air 
after  full  inspiration  causes  it  to  become  warmer.  As  it  becomes  warmer 
it  expands  and  penetrates  the  better  into  the  alveoU.     Retaining  the 


814 


THE    PRACTICE    OF    PEDIATRICS 


air  from  one-half  to  one  niinute  or  longer  is  not  wise.  Becoming  warmer, 
it  continues  to  expand  and  may  overdistend  the  alveolar  walls.  Pro- 
longed holding  of  the  breath  has  also  a  deleterious  effect  upon  the 
heart. 

If,  when  the  child  begins  to  take  deep  breathing  exercises,  he  feels 
dizzy,  he  should  not  at  first  fill  the  lungs  to  their  greatest  capacity  or 
hold  the  breath,  and  each  deep  inspiration  should  be  followed  by  several 
ordinary  oiies.     After  a  few  days  the  dizziness  usually  ceases. 

In  all  cases  deep  breathing  and  respiratory  exercises  should  be  given. 


Fig.    124. — Breathing  exercise.     Inhale  as  arms  are  raised,   sideways,   upward,   to 

vertical. 


They  are  of  special  value  in  malnutrition,  constipation,  flat  chest,  and 
scoliosis. 

Breathing  Exercises. — Take  a  good  standing  posture. 

1.  Inhale  deeply  and  exhale  slowly. 

2.  Place  hands  Hghtly  on  lower  chest.     Inhale  deeply;  exhale. 

.3.  Place  hands  lightly  on  upper  chest,  elbows  well  back  and  down. 
Inhale  deeply;  exhale. 

4.  Inhale  as  arms  are  raised  sideways  to  shoulder  height.     Exhale 
as  arms  are  lowered. 

5.  Inhale  deeply  as  arms  are  raised  forward  and  upward,  to  a  vertical 


FLAT   CHEST  815 

position.  (From  the  beginning  have  elbows,  wrists,  and  fingers  straight, 
palms  facing  each  other  and  separated  by  the  breadth  of  the  shoulders.) 
Exhale  as  arms  are  lowered  sideways. 

6.  Inhale  as  arms  are  raised  sideways  to  vertical.  (Elbows,  wTists, 
and  fingers  straight — turn  palms  up  when  arms  are  shoulder  high.)  As 
vertical  is  reached,  bend  head  shghtly  backward,  stretch  up  and  continue 
inhaling,  while  you  slowly  count  three.  Raise  head;  exhale  as  you 
lower  arms  sideways.     (See  Fig.  124.) 

In  the  illustration  the  wrists  are  strongly  flexed  and  the  palms  are 
not  turned  in,  raising  to  vertical.  The  action  is  stronger.  Either  po- 
sition of  the  hands  may  be  used. 

7.  Arms  at  sides,  elbows,  wrists,  and  fingers  extended.  In  one  quick, 
continuous  movement  raise  arms  forward  and  flex  forearms  upon  the 
chest,  palms  down,  elbows  drawn  well  back.  At  the  same  time  a  step 
forward  is  taken — the  weight  of  the  body  is  supported  over  the  forward 
foot,  the  ball  of  the  other  foot  resting  on  the  floor.  With  the  above  move- 
ment inhale  deeply.     Exhale  as  the  arms  are  lowered  to  side. 

In  Nos.  4,  5,  6,  and  7,  above,  put  the  emphasis  on  the  upward  move- 
ment. In  lowering  the  arms,  keep  chest  high  and  arms  well  stretched, 
but  make  the  movement  an  easy  one. 

If  the  heart  is  weak,  in  the  above  exercises  the  arms  should  not  be 
raised  above  the  level  of  the  shoulders,  and  all  the  exercises  should  be 
done  more  slowly  and  with  less  exertion.  If  the  breathing  becomes 
labored,  or  the  countenance  shows  signs  of  interference  with  circulation, 
the  child  should  rest  until  pulse  and  respiration  return  to  their  usual 
rate. 

Where  deep  respiration  is  an  end  in  itself,  in  addition  to  the  pre- 
ceding breathing  exercises,  others  which  favor  involuntary  deep  breath- 
ing should  be  given.  It  is  important  that  a  good  posture  be  maintained 
throughout. 

Exercises  for  Younger  Children. — 1.  Walking  up-hill  at  a  moderate 
pace  without  stopping. 

2.  Running  in  place,  i.  e.,  executing  a  running  movement  without 
advancing. 

3.  Distance  running — from  fifty  yards  to  a  mile.  The  minimum 
distance  to  begin  with,  and  the  maximum  distance  to  work  up  to,  in 
accordance  with  the  general  condition  and  age  of  the  child. 

4.  Running  games,  such  as  rolling  a  hoop,  playing  tag,  etc. 
Exercises  for  Older  Children. — In   addition   to  those  just  men- 
tioned : 

1.  Games,  such  as  hand-ball,  basket-ball,  tennis,  and  foot-ball  as 
played  by  boys. 

2.  Swimming  for  distance,  when  accompanied  by  a  competent  person 
in  a  boat. 

FLAT  CHEST 

In  flat  chest  the  weight  of  the  body  is  usually  carried  too  far  back, 
the  abdomen  and  head  being  too  far  forward.     The  chest  is  flattened, 


816 


THE    PEACTICE    OF    PEDIATRICS 


with  ribs  depressed,  and  there  is  interference  with  the  proper  expansion 
of  the  lungs.  The  shoulders  often  droop  forward.  The  posture  is  one 
of  general  relaxation. 

Flat  chest  is  of  common  occurrence  among  children  during  the  years 
of  school-hfe.  It  should  be  carefully  corrected  on  account  of  the  del- 
eterious effect  on  the  lungs  and  abdominal  organs.  The  necessity  for 
its  correction  should  be  impressed  upon  the  child.  Attention  to  posture 
and  breathing  is  essential.  The  aim  should  be  to  give  exercises  which 
will  strengthen  the  muscles  of  the  back  and  neck,  deepen  and  broaden 
the  chest,  and  increase  its  elasticity  and  breathing  capacity.     In  addi- 


Fig.  125. — Back  exercise.     Raise  head  and  chest  high. 


fcion  to  the  exercises  given  under  Posture  and  Breathing,  I  have  found 
the  following  of  benefit  in  these  cases : 

1.  Have  the  patient  lie  prone  on  a  hard,  flat  surface,  hold  the  ankles 
while  the  patient  raises  head  and  chest  as  far  as  possible;  the  arms  ex- 
tended and  raised  with  the  body,  the  backs  of  the  hands  being  turned 
toward  each  other  with  the  thumbs  up.  In  the  first  few  treatments, 
the  thumbs  may  be  clasped.  Hold  position  for  from  two  to  five  seconds, 
or  while  counting  from  one  to  five  or  ten.     (See  Fig.  125.) 

2.  With  knees  straight,  bend  trunk  forward  until  the  hands  touch 
the  floor  in  front  of  the  toes,  or  come  as  near  to  floor  as  possible,  then 
raise  the  body  to  best  possible  standing  position.     Keep  weight  well 


KYPHOSIS 


817 


over  balls  of  feet,  raise  the  chest  as  high  as  possible,  stretch  the  arms 
well  down  at  the  side;  wrists,  fingers,  and  elbows  straight.  Hold  this 
position  for  from  two  to  five  seconds  or  while  from  five  to  ten  are  counted. 
The  primary  value  of  the  exercise  is  in  the  elevation  of  the  chest;  sec- 
ondarily, the  back  muscles  are  strengthened,  and,  in  bending  forward, 
the  muscles  that  elevate  chest  are  relaxed  so  that  they  are  better  able 
to  give  a  strong  contraction  when  the  body  is  raised. 

3.  Have  patient  seated  on  a  stool  or  low  chair,  and  stand  behind 
him.  Patient  swings  straight  arms  forward  upward  to  vertical,  palms 
facing.  He  then  turns  palms  forward  and  grasps  your  hands  and  pulls 
his  elbows  backward  and  downward  close  to  sides.  As  he  pulls  them 
downward  resist  his  movement. 


Fig.  126. — Chest  exercise.     Stretch  arms  strongly. 

KYPHOSIS 

Kyphosis,  as  considered  here,  is  an  increase  of  the  normal  curve  in 
the  dorsal  region  of  the  spine,  commonly  called  "round  shoulders," 
produced  by  weakened  muscles  and  bad  habits  of  posture,  or  some- 
times by  improperly  arranged  clothing  and  by  the  occupation  of  the 
child.  These  causative  factors  should  be  removed  as  far  as  possible, 
and,  as  in  all  the  deformities  of  childhood,  attention  should  be  given  to 
posture,  breathing,  arrangement  of  clothing,  etc. 

The  treatment  given  under  Flat  Chest  is  appropriate  here,  as  the 
two  conditions  are  often  associated.  The  following  exercises  may  be 
added: 

1.  Raise  arms  sideways  to  height  of  shoulders.  Bend  head  back- 
ward with  chin  drawn  in  and  at  same  time  turn  palms  strongly  upward. 


52 


818 


THE    PRACTICE    OF   PEDIATRICS 


When  patient  has  learned  to  do  this  well,  as  the  head  goes^  back  the 
arms  may  be  raised  to  vertical. 

2.  Flex  forearms  upon  chest,  palms  down  and  elbows  well  drawn 
back,  shoulders  level.  Inchne  head  sHghtly  backward  and  fling  arms 
forcibly  sideways. 

3.  Raise  arms  sideways  to  shoulder  level,  turn  palms  up,  make  three 

short  circles  with  arms,  stop- 
ping with  the  backward 
movement.  Raise  arms  a 
few  inches,  stretch  out  and 
up.  Bring  arms  backward 
and  downward  to  sides.  (See 
Fig.  126.) 

4.  Hanging  Exercises. — A 
short  curtain  pole,  IJ^  inches 
in  diameter,  may  be  placed  in 
a  doorway  at  desired  height. 
Strong  enough  sockets  can 
be  obtained  at  a  hardware 
store. 

(a)  Hang  with  over- 
grasp. 

(6)  Hang  and  swing. 

Hanging  is  of  much  value 
in  kjTjhosis  and  flat  chest 
on  account  of  its  effect 
upon  the  spine  and  spinal 
muscles. 

(c)  Holding  patient  (see 
Fig.  127);  trunk  of  patient 
resting  against  your  body. 

(d)  Holding  patient; 
upper  back  resting  only 
against  body. 

Exercises  "c"  and  "d" 
are  used  for  the  passive 
stretching  of  the  lumbar 
and  dorsal  portions  of  the 
spine,  the  dependent  part 
of  patient's  body  acting  as 
weight  to  stretch  the  spine. 
Hold  from  one-fourth  to  one-half  minute.     Repeat  several  times. 

5.  Patient  sitting  on  stool  or  chair  with  arms  forward,  midway  be- 
tween horizontal  and  vertical,  palms  facing.  Make  resistance  as  arms 
are  separated  backward  and  downward.     (See  Fig.  128.) 

6.  Forearms  flexed  upon  upper  arms,  hands  closed  and  facing  the 
front  of  shoulders.  Strongly  rotate  forearms  outward  and  backward. 
(See  Fig.  129.) 


Fig.  127. — Weight  of  pelvis  and  lower  limbs  to 
stretch  the  lumbar  spine. 


KYPHOSIS 


819 


7.  Patient  sits  astride  a  stool  and  raises  the  arms  sideways.  With 
an  assistant,  either  the  child's  mother  or  nurse,  on  one  side,  and  your- 
self on  the  other,  each  grasp  the  patient's  hand  with  one  hand  and  place 
the  other  hand  on  his  back  in  the  region  of  greatest  deformity.  Have 
the  patient  pull  the  elbows  close  backward  and  downward  to  the  sides, 
against  resistance.  At  the  same  time  gentle  and  firm  pressure  is  made 
on  the  back.  ^ 

8.  Patient  sits  on  stool,  places  hands  low  on  hips,  fingers  forward 
and  wrists  straight,  elbows  drawn  well  back.  Let  him  bend  for^vard 
from  hips  with  back  straight.     Place  your  hands  over  the  regions  of 


Fig.  128. — Sit  behind  patient  and  give  resistance  on  back  of  wrists  as  he  separates 

his  arms. 


greatest  deformity  and  have  patient  raise  the  body  against  resistance. 
The  back  must  be  kept  straight,  head  erect,  and  chest  well  arched. 
When  the  patient  can  do  this  well,  his  hands  may  be  placed  on  the  back 
of  the  neck,  instead  of  on  the  hips. 

9.  The  patient  stands,  raises  arms  sidewaj^s,  shoulder  high;  bends 
trunk  forward  from  hips,  back  straight,  and  raises  arms  to  vertical. 

10.  Patient  lies  face  downward  over  end  of  couch  or  table,  the  whole 
body  straight,  hips  and  thighs  only  resting  on  table  and  held.  Hands 
back  of  neck.  Bend  body  forward  until  the  chest  touches  the  seat  of  a 
chair,  then  raise  body  as  high  as  possible.     (See  Fig.  130.) 

11.  While  the  patient  is  in  dorsal  recumbency,  with  one  hand  hold 


820 


THE    PRACTICE    OF    PEDIATRICS 


his  knees  firmly  to  prevent  his  body  moving  and  have  the  other  hand 
under  his  shoulders.  Have  an  assistant  (any  adult)  draw  the  patient's 
arms  as  strongly  as  possible  in  a  line  with  his  head  and  body,  but  away 
from  them.  When  this  is  done,  with  the  hand  under  the  shoulders, 
gently  but  strongly  raise  his  shoulders  and  body  several  inches  from  the 
table,  hold  while  you  count  from  five  to  ten,  lower,  and  relax.  Repeat 
from  five  to  ten  times. 

12.  With  children  who  are  not  strong  begin  with  exercises  in  a  re- 
cUning  posture:  • 

(a)  Reclining  position.     Arms  extended  at  right  angle  to  the  body, 

palms  facing  each  other. 
Separate  arms  against  re- 
sistance. 

(6)  RecHning  position. 
Arms  extended  beyond  head 
in  fine  with  the  body.  Bring 
arms  sideways,  downward, 
against  resistance. 

(c)  Deep  breathing. 

(d)  No.  3  under  Posture 
Exercises,  but  body  arched 
only  from  hips  upward,  in- 
stead of  from  heels. 

In  the  treatment  of 
kyphosis  or  flat  chest  with 
lordosis  this  exercise  may 
be  given.  While  a  child  is 
taking  deep  breathing  or 
chest  raising  alone,  lying  in 
a  dorsal  position,  with  or 
without  the  shoulders  being 
raised  by  some  supporting 
object,  place  your  hand 
under  the  small  of  his  back; 
after  the  chest  has  been 
fully  raised,  have  him  en- 
deavor to  press  his  back 
against  your  hand  without  lowering  his  chest.  This  may  be  done  from 
50  to  100  times.  Later,  the  same  exercise  may  be  done  in  sitting  or 
standing  positions,  the  lumbar  region  being  pressed  backward  while  the 
chest  is  elevated  and  forward.  The  lumbar  spine  should  be  brought 
back  only  until  the  entire  back  is  in  one  straight  fine. 

The  spinal  muscles  should  be  massaged  to  make  them  phable. 

SCOLIOSIS 

Scoliosis,  or  lateral  curvature  of  the  spine,  is  a  condition  in  which 
the  spine  deviates  in  whole  or  in  part  to  one  side  or  the  other  of  the  me- 
dian line.     It  is  accompanied  by  the  rotation  of  the  vertebrae,  though 


Fig.  129. — Bring  forearms  back  as  far  as  possible. 


SCOLIOSIS 


821 


in  some  cases  the  amount  of  rotation  is  so  slight  that  it  is  not  easily  de- 
tected; in  other  cases  the  rotation  is  marked  in  comparison  with  the 
amomit  of  lateral  curvature. 

The  treatment  of  curvatures  resulting  from  such  diseases  as  tuber- 
culosis or  caries  of  the  spine,  rickets,  etc.,  will  not  be  considered,  but 
only  the  simple  curvatures  which  occur  in  cases  of  general  debility, 
muscular  weakness,  or  are  the  result  of  faulty  habits  of  posture,  a  short 
leg,  certain  occupations,  etc. 

Diagnosis. — In  the  treatment  of  scohosis,  much  depends  upon  a 
careful  diagnosis.  As  far  as  possible  all  the  etiologic  factors  should  be 
ascertained:  the  heredity,  general  constitution,  and  temperament  of 
the  patient;  the  general  appearance,  condition  of  skin,  the  musculature, 
its  structure  and  tonicity,  should  be  closely  scrutinized.     The  patient's 


Fi£ 


130. — Movement  may  start  from  position  of  complete  fiexion  or  i)artial  tlexion 
with  body  resting  on  seat  of  chair  or  on  shorter  stand  or  table. 


habits  of  posture  while  standing  and  sitting,  especially  when  he  is  un- 
conscious of  observation,  should  be  studied  carefully.  Inquiry  should 
be  made  as  to  position  during  sleep,  and  if  a  school-child,  concerning  the 
desk  and  chair,  and  position  while  writing,  etc. 

For  examination  the  back  should  be  bared  down  to  the  level  of  the 
trochanters,  when  the  height  of  shoulders,  height  and  prominence  of 
hips,  position  of  the  scapulae  and  their  relation  to  the  spine,  the  lines 
running  from  the  tips  of  the  ears  to  the  tips  of  shoulders,  and  the  posi- 
tion of  arms  as  they  hang  at  the  sides,  should  all  be  noted.  The  posi- 
tion of  the  spine  itself  and  its  relation  to  points  mentioned  should  also 
be  closely  observed  when  the  patient  is  standing  in  his  usual  posture, 
and  again  when  he  is  standing  in  his  best  possible  position.  The  posi- 
tion of  the  spinous  processes  should  be  marked  with  a  flesh  pencil  and 


822  THE    PRACTICE    OF   PEDIATRICS 

the  curve  carefully  studied  out;  the  contour  and  relative  size  of  legs 
should  be  noted  and  the  feet  should  be  examined.  To  ascertain  the 
amount  of  rotation,  the  patient  should  be  made  to  take  the  Adams 
position.*  If  any  difference  is  found  in  the  height  of  the  hips,  a  careful 
measurement  of  the  legs  should  be  made.  Another  important  point 
to  be  determined  is  the  flexibility  of  the  spine,  for  to  a  great  extent  the 
diagnosis  depends  upon  this. 

On  the  front  of  the  body,  the  position  of  ribs,  end  of  sternum,  um- 
bihcus,  and  the  tension  of  the  abdominal  muscles  should  be  noted. 

Besides  the  above  examination,  it  is  well  to  inquire  into  the  history 
of  the  patient,  as  to  diseases  of  childhood,  present  ailment,  liability  to 
certain  diseases,  as  to  amount  of  exercise,  both  outdoors  and  indoors, 
and  as  to  the  condition  of  the  digestive  organs.  Examine  heart  and  lungs. 
Certain  measurements  may  be  taken,  such  as  height,  weight,  height 
sitting,  girth  of  neck,  chest,  waist,  hips,  biceps,  calves  and  insteps,  depth 
of  chest  and  abdomen,  and  breadth  of  shoulders,  chest,  and  waist. 

I  have  found  the  best  method  of  recording  to  be  by  photographing 
the  patient,  using  a  thread  screen,  the  spinous  processes  and  lower  bor- 
der of  scapulae  having  been  outHned  with  flesh  pencil  or  dots  of  ink. 
To  record  the  rotation,  a  lead  tape  may  be  molded  across  the  posterior 
thorax  at  point  of  greatest  convexity,  while  the  patient  is  in  the  Adams 
position,  and  the  tape  carefully  removed  and  its  outline  traced  on  paper. 

The  curve  may  be  a  single  long  curve,  a  double  or  a  triple  one.  En- 
deavor to  find  out  which  is  the  primary  and  which  the  secondary  or 
compensatory  curve,  for  the  normal  position  of  the  spine  is  the  result 
of  the  adjustment  of  the  weight  of  the  body  around  the  center  of  gravity, 
in  order  to  balance  the  body  while  standing  or  sitting,  and  if  there  is  a 
change  in  the  normal  adjustment  of  the  weight  in  one  part,  there  must 
soon  be  a  corresponding  change  elsewhere,  so  that  if  there  is  a  left  con- 
vexity in  the  lumbar  region,  there  will  be  a  compensatory  curve  to  the 
right  in  the  dorsal. 

In  a  well-marked  case  of  scoliosis  the  child  should  be  kept  out  of 
school  for  several  months  or  a  year.  He  should  be  allowed  to  retire 
early  and  sleep  late,  with  a  good  rest  at  midday. 

Treatment. — The  treatment  should  be  both  general  and  local.  In 
the  general  treatment,  carry  out  a  thorough  hygienic  regime,  which 
includes  exercise  in  the  open  air,  baths,  attention  to  diet  and  bowels, 
clothing,  and  general  Hght  exercise  for  muscle-building  and  stimulation 
of  the  circulation,  respiration,  and  digestion.  One  of  the  most  important 
things  is  to  train  the  habits  of  posture. 

The  patient  should  be  taught  to  lie  on  the  side  that  will  assist  in 
straightening  the  curve,  or  upon  his  back  in  a  good  general  posture. 

Special  Treatment. — Massage  and  exercises  which  act  strongly  upon 
the  spine  itself,  and  suspension — (a)  bar;  (6)  in  Sayre's  suspension  ap- 
paratus, with  and  without  pressure — I  have  found  most  useful.     It  is 

*Patient  stands  with  heels  together,  knees  well  stretched,  bends  body  forward 
from  hips;  head  and  arms  hanging  forward. 


SCOLIOSIS 


823 


occasionally  beneficial  for  a  patient  to  wear  a  plaster  cast  or  leather 
jacket  during  the  day  between  treatments. 

At  first  only  general  movements  are  given — those  in  which  both  sides 
of  the  body  are  used  equally,  such  as  the  movements  found  under 
Posture  and  Breathing.  A  little  later  the  exercises  under  Flat  Chest 
and  Kyphosis  may  be  added,  with  simple  movements  of  the  body  to 
strengthen  the  spinal  muscles  and  make  the  spine  more  flexible. 

The  following  may  be  used:  body-bending  forward,  backward,  to 
right  and  to  left,  and  body- 

wm 


twisting  to  right  and  left. 
These  movements  may  be 
done  sitting  or  standing, 
and  with  the  hands  at  the 
hips,  back  of  neck,  or  ex- 
tended over  head. 

The  bendings  and  twist- 
ings  to  right  and  left  may 
be  taken  with  stronger  effect 
when  the  trunk  is  inclined 
forward  from  the  hips  with 
chest  and  head  held  well 
erect. 

In  giving  a  new  exercise 
the  body  should  be  bare,  in 
order  that  the  effects  may 
be  carefully  noted. 

In  giving  corrective 
bending  and  twisting  move- 
ments the  bending  should 
be  toward  the  side  of  the 
convexity,  with  added  pres- 
sure at  the  point  of  greatest 
curvature,  and  the  twisting 
movement  toward  the  side  of 
the  concavity,  with  pressure 
over  the  point  of  the  con- 
vexity. The  following  are 
some  of  the  special  exercises: 
(A  tj'pical  S-shaped  curve, 
convexities,  right  dorsal  and 
left  lumbar,  has  been  taken 
to  illustrate  the  treatment. 


Fig. 


131. — Spine  being  stretched  by  weight  of 
body,  pressure  over  convexities. 


These  exercises  can  be  reversed.     A  single 
or  triple  curve  will  have  to  be  studied  out  with  back  bared.) 

1.  Hanging  from  bar;  pressure  over  convexities.     (See  Fig.  131.) 

2.  Hanging  from  bar.     Place  your  hand  over  point  of  greatest  con- 
vexity, and  push  patient's  body  sideways. 

3.  Hanging  from  bar.     Have  patient  extend  the  leg  corresponding 
to  the  side  of  lumbar  convexity  backward  against  resistance. 


824 


THE    PEACTICE    OF    PEDIATEICS 


4.  Lying  prone  on  table;  left  hand  on  neck,  right  on  hip:  raise  body 
(see  Fig.  125,  but  with  hands  placed  in  accordance  with  text). 

5.  Lying  prone  on  table;  hands  on  neck.  Carry  patient's  legs  to- 
ward the  convexity  of  the  lumbar  region. 

6.  Patient  sits  astride  a  stool;  hands  back  of  neck.  Twist  body  to 
left;  make  pressure  over  right  dorsal  region. 

7.  Sitting  on  stool;  left  hand  back  of  neck,  right  at  hip;  right  leg 
extended  backward.  Bend  body  forward;  resist  patient  as  he  raises 
body,  using  pressure  over  convexities.     (See  Fig.  132.) 


Fig.  132. — Body  raising  with  pressure  over  convexities. 


8.  Standing :  flex  forearms  on  upper  arms,  with  fingers  pointing  over 
shoulders.  Extend  left  arm  upward  and  right  arm  downward  and  back- 
ward, and  extend  left  leg  backward. 

9.  Using  wand,  that  is,  about  twelve  or  fourteen  inches  shorter  than 
the  height  of  the  body ;  grasp  at  ends,  with  elbows  straight ;  swing  strongly 
from  front  of  thighs  to  the  right,  sideways,  backward,  until  the  wand 
is  at  a  perpendicular  and  in  line  with  the  spine.  The  body  arches  from 
heels  to  head.     (See  Fig.  133.) 

"Key-note  position."*  Left  arm  extended  upward;  right  arm  side- 
ways.     (See  Fig.  134.) 

*  Key-note  position  is  the  position  of  arms  by  which  the  spine  assumes  its  best 
position. 


EMPYEMA  825 

10.  (a)  Take ''key-note  position"  standing.  Stretch  body  for  from 
two  to  five  seconds. 

(h)  Take  "key-note  position."     Marching  on  balls  of  feet. 

Do  not  give  more  than  three  or  four  special  exercises  in  any  one  treat- 
ment, and  follow  each  of  them  with  a  marching  exercise,  such  as  10  h, 
or  some  breathing  exercise. 

EMPYEMA 

The  indication  for  therapeutic  gymnastics  is  the  promotion  of  the 
recovery  of  the  impaired  function  caused  by  the  compressed  lung,  the 
adhesions  present,  and  the  contracted  chest-walls.  In  the  neglected 
cases  we  also  have  the  sequelae  in  the  deformed  chest  and  spine,  which 
should  receive  all  possible  treatment. 

The  initial  measures  are  those  which  may  be  permitted  while  the 
patient  is  yet  in  bed,  and  consist  of  posture  and  the  lightest  forms  of 
exercise.  The  posture  immediately  following  operation  is  that  of  lying 
on  the  affected  side,  for  reasons  of  better  drainage  and  immobihty. 
When  the  necessity  for  this  posture  has  passed,  children  who  are  old 
enough  should  be  made  to  lie  on  the  sound  side  for  several  hours  each 
day.  A  good-sized  cloth  bag,  partially  filled  with  bran  or  salt,  properly 
covered,  or  a  large  roll  of  cotton,  may  be  placed  crosswise  under  the 
sound  side  of  the  chest  during  the  exercise  periods.  This  pad  or  bag 
further  restricts  the  action  of  the  chest  on  the  sound  side  and  increases 
the  inspiratory  action  of  the  affected  side.  The  exercises  practised 
may  be  those  of  deeper  or  deep  breathing,  for  from  five  to  ten  minutes, 
two  or  more  times  a  day.  Some  authorities  begin  with  deep  breathing 
as  early  as  the  fourth  or  fifth  day  following  the  operation.  The  effect 
of  deep  breathing  may  be  increased  by  the  arm  on  the  affected  side  being 
held  over  the  head  or  extended  beyond  the  head  during  the  deep  breath- 
ing; or  the  arm  may  be  raised  to  either  position  upon  each  deep  inspira- 
tion. 

The  Sylvester  method  of  artificial  respiration  may  be  used  once  or 
twice  daily,  executing  it  very  gently,  depending  upon  the  age  of  the 
patient  and  the  condition  present.  The  stretching  of  the  extended  arms 
may  be  prolonged;  the  child's  body  may  be  bent  toward  the  sound  side 
at  the  end  of  the  inspiratory  movement. 

During  breathing  exercises,  while  the  patient  is  lying  on  the  sound 
side,  place  your  hand  under  the  body;  gently  raise  it  as  he  inhales. 

Some  writers  urge  the  rule  of  getting  the  patient  up  as  soon  as  pos- 
sible after  a  week  of  exercise  in  bed,  as  the  ensuing  exertion  is  a  desirable 
aid  in  lung  expansion.  We  may  still,  however,  have  the  child  take  a  re- 
cumbent position  while  he  takes  his  breathing  exercises.  When  the 
child's  strength  warrants,  the  deep  breathing  exercises  may  be  practised 
while  he  is  sitting  and  standing. 

Osier  refers  to  Naunyn's  exercise,  patient  sitting  in  an  arm-chair 
with  sound  side  bending  over  arm  of  chair,  grasping  a  rung.  While 
holding  the  rung,  forcibly  inhale.  The  same  effect  is  obtained  when  the 
deep  breathing  exercises  are  combined  with  the  various  lateral  bending 


826  THE    PRACTICE    OF    PEDIATRICS 

movements  of  the  body  to  the  sound  side,  with  or  without  the  added 
combination  of  arm  movements,  or  the  use  of  the  arm  only  on  the  affected 
side.  The  various  breathing  exercises  should  be  practised  from  ten 
to  thirty  minutes  a  day,  each  exercise  being  repeated  from  5  to  20  times. 
To  avoid  overtiring,  give  a  short  rest  after  every  two  or  three  minutes 
of  exercise. 

Exercises. — Standing. — 1.  Deep  inhalation,  full  exhalation,  arms 
hanging. 

2.  Deep  inhalation,  full  exhalation,  hands  back  of  head. 

3.  Deep  inhalation  as  arms  are  raised  sidewise,  shoulder  height. 
Exhale  as  arms  are  lowered. 

4.  Deep  inhalation  as  arms  are  raised  sidewise  overhead,  elbows 
straight.     Exhale  as  arms  are  lowered  with  bent  elbows. 

5.  Flex  wrists,  but  keeping  elbows  straight;  repeat  No.  4.  In  the 
following  exercises  the  one  hand  or  arm  refers  to  the  one  on  the  affected 
side: 

6.  No.  2,  one  hand  only  back  of  head,  other  arm  by  the  side. 

7.  No.  3,  only  one  hand  being  raised,  other  by  the  side. 

8.  No.  4,  only  one  arm  being  raised,  the  other  by  the  side. 

9.  No.  5,  only  one  arm  being  raised,  the  other  by  the  side. 

10.  With  the  hand  in  position,  as  in  Numbers  6,  7,  8  and  9,  inhale 
deeply,  bending  toward  the  sound  side. 

11.  Nos.  6,  7,  8,  and  9  to  be  executed,  while  carrying  the  arms  to 
position  and  at  the  same  time  bending  the  body  toward  the  sound  side. 

12.  Charge  to  front  with  leg  on  affected  side  (long  stride,  bending 
knee).  Bend  body,  touch  floor  in  front  of  toes  with  corresponding  hand. 
Flex  wrist,  with  straight  elbow,  raise  arm  to  overhead  position,  at  the 
same  time  inhale.  Exhale  as  you  bend  forward  again  to  floor,  with 
flexed  arm.     Repeat  from  three  to  five  times.     Step  back  to  position. 

13.  Charge  to  side,  inhale  as  you  raise  arm  sidewise  to  overhead  and 
bend  body  to  the  sound  side;  exhale  as  you  straighten  body  and  lower 
arm;  repeat  three  to  five  times;  step  back  to  position. 

During  this  stage  of  treatment  one  or  another  of  the  following  meas- 
ures, v/hich  have  been  recommended  by  the  various  writers,  may  now 
and  then  be  used  for  from  five  to  ten  minutes  of  the  exercise  period. 
These  are:  blowing  bubbles  and  various  wind  instruments,  use  of  the 
spirometer  and  of  Wolffe's  or  James'  bottle  apparatus.  Their  use  should 
be  limited  to  adding  variety  or  interest  to  the  treatment  of  the 
child. 

As  the  patient's  strength  increases  the  various  out-of-door  exercises 
and  games  which  more  strongly  stimulate  the  circulatory  and  respira- 
tory apparatus  should  be  made  use  of.  These  are:  fast  walking,  hill- 
walking,  rope-skipping, — backward  as  well  as  forward, — running, 
horseback  riding,  bicycle  riding,  the  various  games  of  tag,  ball,  and  swim- 
ming— breast  and  back  stroke  preferred— for  distance  and  speed.  These 
exercises  should  be  done  with  the  chest  expanded  and  head  erect.  Ten 
to  twenty  minutes  of  the  breathing  exercises  should  be  kept  up  in  addi' 
tion  to  the  out-of-door  exercise,  as  long  as  the  case  needs  treatment. 


EMPHYSEMA 


827 


After  exercising,  a  patient  should  always  rest  from  twenty  to  thirty 
minutes  in  a  reclining  position. 

If  the  case  presents  a  possibility  of  the  formation  of  scoliosis,  a  tho- 
racic support  should  be  worn  in  the  intervals  between  the  treatments, 


Fig.  133. — Swing  strong- 
ly to  this  position  without 
bending  elbows. 


Fig.  134. — Key-note  position.  Arm  corresponding 
to  low  shoulder  is  raised.  Used  to  maintain  a  better  posi- 
tion of  the  spine  during  certain  exercises  and  marches. 


which  would  keep  the  trunk  in  a  straight  line  without  interfering  with 
the  respiration.  The  use  of  a  bar  and  suspension  apparatus  each  day 
for  from  five  to  ten  minutes  is  also  advised  as  a  preventive  measure. 

EMPHYSEMA 

While  the  physical  changes  of  emphysema  are  usually  not  marked  in 
children,  ten  to  twenty  minutes  a  day  of  the  following  exercises  will 
prove  of  benefit,  even  in  such  cases. 


828  THE    PRACTICE    OF    PEDIATRICS 

The  patient  should  avoid  strain  or  overfatigue. 

In  order  to  facihtate  exhalation  without  alveolar  strain,  all  forced 
exhalations  produced  by  exertion  or  used  as  special  exercises  should  be 
done  with  the  mouth  open. 

While  expiratory  exercises  are  indicated  in  emphysema,  inspiratory 
exercises  are  also  of  value,  as  they  aid  in  maintaining  the  functional 
power  of  the  unaffected  portions  of  the  lungs,  and  in  consequence  the 
patient  suffers  less  from  dyspnea. 

In  marked  cases  of  emphysema  the  breathing  is  mainly  diaphrag- 
matic. Any  impairment  of,  or  interference  with,  the  action  of  the  dia- 
phragm brings  on  dyspnea.  Practice  and  improvement  of  abdominal 
breathing  are  of  value. 

A  distended  or  bulging  chest-wall  may  be  supported  by  a  tight  elastic 
band  covering  the  ribs  from  the  axilla  down. 

Frequent  short  periods  of  rest  in  bed  lessen  the  accumulative  prod- 
ucts of  exertion. 

Respiratory  Exercises  with  Manual  Aid. — 1.  The  Sylvester  and 
Satterthwaite  methods  of  artificial  respiration  may  be  used  from  two  to 
five  minutes  twice  a  day.     Expel  as  much  air  as  possible  by  pressure. 

2.  Patient  lying  on  his  back,  stand  by  his  side  with  your  hands  on 
either  side  of  his  chest.  After  he  has  inhaled  as  completely  as  possible, 
he  slowly  exhales  through  the  open  mouth;  at  the  same  time  presses 
alternately  with  hands  from  the  base  of  his  lungs  to  the  apices.  He 
ejaculates  "ah!"  with  each  pressure  until  his  exhalation  is  completed. 
Practise  five  to  ten  minutes  a  day. 

3.  Gerhardt's  Method. — ^With  your  hands  on  the  side  of  patient's 
chest,  press  both  sides  of  the  chest  as  the  patient  exhales  ordinarily. 
Repeat  20  times  per  minute  for  ten  minutes,  three  or  four  times  daily. 

4.  McKenzie's  Method. — With  a  four-inch  support  (roll  of  cloth) 
under  patient's  lower  thorax,  his  hands  under  his  head,  and  his  chest 
expanded  in  inhalation,  facing  the  patient's  chest  press  both  sides  of 
his  thorax,  the  patient  exhaling  at  the  same  time.  Repeat  10  times  a 
minute  from  two  to  four  minutes. 

Active  Exercises. — Deep  Breathing  (Standing). — 1.  Inhale  as  arms  are 
raised  sideways  upward,  elbows  straight.  Exhale  as  arms  are  lowered 
sideways  downward.     Repeat  5  to  10  times. 

2.  Inhale  as  arms  are  raised  forward  upward,  elbows  straight.  Ex- 
hale as  arms  are  lowered  forward  downward.     Repeat  5  to  10  times. 

3.  Arms  overhead.  Exhale  as  you  bend  forward  and  touch  floor. 
Inhale  as  you  raise  upward  and  bring  arms  to  position  overhead.  Re- 
peat 5  to  10  times. 

4.  Sitting,  inhale  through  nostrils  as  much  as  possible;  lean  a  Uttle 
forward  as  you  exhale  through  the  mouth.     Repeat  5  times. 

5.  Lying  on  back — abdominal  respiration.  Hands  back  of  neck; 
draw  as  much  air  in  as  possible  through  nostrils;  the  abdominal  wall 
expanding  forward  throughout  the  inhalation,  the  upper  thorax  not  ex- 
panding; exhale.  Practise  the  abdominal  respiration  also  while  sitting 
and  standing.     Repeat  5  to  10  times  in  each  position. 


CONGENITAL   ATAXIAS  829 

Development  of  the  Accessory  Muscles  of  Expiration. — Thoracic — 
1.  Standing  Position. — Arms  flexed,  hands  at  the  sides  of  the  shoulders, 
strike  strongly  the  ulnar  borders  of  the  hands  together,  in  front  of  chest. 
Repeat  10  to  25  times. 

2.  Arms  extended  sideways,  shoulder  height.  Swing  arms  strongly 
forward,  crossing  each  palm  slapping  the  opposite  shoulder.  Repeat  10 
to  25  times. 

3.  Arms  extended  overhead.  Full  arm  circle.  Arms  crossing  in- 
ward as  a  swing  is  made  strongly  downward  and  up  sideways  to  over- 
head.    Repeat  5  to  15  times. 

Abdominal. — 1.  Lying  on  Back. — Raise  body  to  sitting  position. 
Repeat  2  to  5  times. 

2.  Raise  both  legs  up  to  a  perpendicular  position  without  raising 
the  hips  from  the  floor.     Repeat  2  to  5  times. 

3.  Flex  both  thighs  upon  abdomen,  the  legs  being  flexed  on  the  thighs 
at  the  same  time.     Repeat  2  to  10  times. 

4.  If  Nos.  1,  2,  and  3  are  too  difficult,  then  alternate  raising;  right 
leg  to  perpendicular,  lower;  left  leg  to  perpendicular,  lower.  Repeat 
6  to  20  times. 

The  exercises  should  be  practised  twice  a  day.  Beginning  with 
fifteen  minutes,  the  time  may  be  extended  until  the  patient  is  taking 
thirty  minutes  twice  a  day  as  he  becomes  stronger.  Better  exercise 
slowly.     When  beginning  to  tire,  rest  for  a  few  minutes. 

Compressed-air  Bath  and  Rarefied  Air  Apparatus. — These  methods 
of  treating  emphysema  have  been  of  value  in  treating  adults.  They 
are  not  practical  with  young  children.  If  apparatus  is  accessible,  they 
might  be  tried  with  older  children.  Exhalations  into  a  rarefied  air  ap- 
paratus increase  the  amount  of  air  exhaled  and  make  the  breathing 
easier.  The  Waldenberg  apparatus  is  one  of  the  best.  The  compressed 
air  bath,  while  apparently  not  as  suitable  a  measure  of  treatment,  has 
really  proved  of  greater  benefit,  in  that  it  benefits  by  aiding  in  the  re- 
moval of  the  causes  of  emphysema,  viz.,  bronchial  catarrh  and  spasm. 
It  increases  the  vital  capacity  and  respiratory  force.  A  course  of  from 
20  to  30  baths  are  usually  given,  each  bath  lasting  two  hours;  during 
the  first  half-hour  the  pressure  is  increasing  and  then  the  maximum  pres- 
sure is  maintained  for  an  hour,  and  during  the  last  half-hour  the  pres- 
sure is  gradually  reduced  to  normal.  The  lessening  dyspnea  and  gen- 
eral benefit  derived  from  a  course  of  baths  remain  for  a  considerable 
period  of  time  after  such  a  course  has  been  finished. 

CONGENITAL  ATAXIAS 

The  ataxias  of  childhood,  to  which  we  refer,  are  hereditary  cerebellar 
ataxia  and  hereditary  spinal  ataxia.  Most  observers  have  described 
them  as  beginning  to  develop  at  the  age  of  eight  or  ten  years;  one  or 
two  observers  have  mentioned  a  much  earher  period,  stating  that  the 
symptoms  generally  appear  at  the  age  of  three  or  four  years,  and  that 
the  cases  may  be  congenital. 

Cases  upon  which  this  treatment  is  based  were  congenital;  the  de- 


830  THE    PRACTICE    OF    PEDIATRICS 

velopment  of  the  physical  movements  was  retarded  and  defective 
from  the  beginning,  and  in  one  case  of  hereditary  spinal  ataxia  the  phy- 
sical act  of  nursing  was  also  defective. 

Hereditary  cerebellar  ataxia  is  characterized  by  the  involvement 
both  of  the  upper  and  lower  limbs  at  the  same  time,  although  the  upper 
limbs  may  not  be  ataxic  to  the  same  degree  as  the  lower.  The  gait 
is  reeling,  uncertain,  with  the  feet  wide  apart,  body  bent  forward,  the 
weight  of  the  body  being  supported  mainly  upon  the  balls  of  the  feet, 
the  toes  inclining  inward,  locomotion  at  times  being  interfered  with  by 
the  crossing  of  the  legs.  One  leg  is  usually  more  ataxic  than  the  other. 
The  reflexes  may  be  increased.  The  speech  is  hesitating,  defective,  and 
explosive,  but  audible. 

Hereditary  spinal  ataxia  {Friedreich's  ataxia)  is  characterized  by  its 
beginning  in  the  lower  limbs,  gradually  extending  to  the  upper  limbs, 
and  finally  involving  the  organs  of  speech.  The  symptoms  are  vertigo; 
swaying  from  side  to  side  on  standing;  marked  muscular  weakness, 
especially  of  the  extensors  and  abductors  (paralysis  may  follow);  con- 
tractures of  the  flexors  and  adductors;  scoliosis  and  talipes  resulting, 
first,  postural,  through  muscular  weakness,  later  becoming  fixed;  rheu- 
matoid pains;  and  diminution  or  loss  of  the  patellar  reflex.  The  head  is 
held  to  one  side  in  a  clonic  spasm,  but  turns  from  one  side  to  the  other 
every  day  or  two.  One  leg  is  more  ataxic  than  the  other.  The  move- 
ments are  characterized  by  rigidity  and  incoordination;  the  articulation 
is  scanning  and  explosive,  and  oftentimes,  for  days,  the  patient  cannot 
speak  above  a  whisper. 

Dana  states  that  there  may  be  a  mixed  or  transitional  hereditary 
cerebellar  and  spinal  ataxia. 

Some  observers  state  that  there  is  defective  mentality,  and  that  the 
patients  possess  a  violent  temper.  I  have  not  found  either  to  be  true — 
the  temper  being  no  different  from  that  which  one  would  find  in  a  little 
patient  otherwise  ill  for  as  long  a  period,  and  who  was  not  perfectly 
understood.  The  speech,  or  the  poise  of  the  head,  may  suggest  deficient 
mentality,  but  I  have  found  these  children  affectionate,  observing,  and 
rational,  and  showing  hereditary  indications  of  brightness  in  mechanical, 
mathematical,  or  methodic  lines. 

In  beginning  treatment,  study  the  patient's  capability  for  coordinate 
action.  Do  this  throughout  the  entire  course.  When  you  have  de- 
cided upon  the  exercises  to  be  given,  show  them  to  the  patient  in  detail, 
explaining  them  fully,  so  that  he  may  understand  what  effort  is  required, 
and  occasionally,  in  teaching,  repeat  these  illustrations  and  explanations. 

Accuracy  is  of  the  first  importance.  If  there  is  lack  of  control  in 
movement,  pause  and  hold  patient  in  correct  position  while  you  count 
from  one  to  four  or  ten  before  resuming  movement.  Follow  that  prac- 
tice as  long  as  it  is  necessary,  and  at  every  tendency  toward  losing  con- 
trol.    Slow  and  accurate  work  first,  later  more  rapid  work. 

While  learning  an  exercise  of  coordination  permit  patient  to  use  his 
eyes  to  watch  his  limbs,  in  order  that  the  coordinate  centers  may  thus 
be  reinforced  or  aided.     Next  rely  only  upon  his  muscular  sense  for 


CONGENITAL  ATAXIAS  831 

correct  execution,  and  at  last  have  the  eyes  closed  in  order  to  eliminate 
the  relationship  of  surrounding  objects,  which  might  aid  in  the  execution. 
A  reclining  posture  is  assumed  for  coordinate  training,  where  the  patient 
is  unable  to  stand. 

Do  not  expect  a  child  to  cooperate  with  you  in  attention  or  efforts 
to  make  his  physical  movements  accurate  when  he  is  left  to  himseK,  for 
it  is  rarely  done.  The  coordination  must  become  reflex.  The  training 
must  be  carried  to  the  extent  of  unnecessary  capability.  ''The  keynote " 
must  be,  as  with  the  orthopedist,  overcorrect,  for  the  correct  execution 
of  work  under  observation  would  not  be  sufficient  to  insure  coordinate 
action  the  moment  a  child  attempts  to  do  things  alone,  or  when  he  is 
tired,  or  when  his  attention  is  given  to  other  objects. 

The  aim  in  treatment  should  be  in  keeping  with  a  child's  natural 
sphere  in  life.  Childhood  is  the  time  of  muscular  activity  and  growi^h; 
it  is  the  period  of  play  and  games.  When  a  child  is  able  to  play  at  all, 
if  left  to  himself  he  will  not  stop  for  rest,  when  he  begins  to  tire  or  fall; 
he  will  do  so  only  when  the  game  is  ended  and  his  companions  finish. 
Play,  therefore,  serves  only  to  increase  the  incoordination,  because  of 
overexertion.  To  make  a  child  capable  of  walking  or  running  at  all, 
makes  him  eager  to  play  when  others  play;  but  it  is  like  the  fencing  or 
boxing  of  two  men,  one  of  whom  completely  outclasses  the  other,  whose 
native  quickness  and  strength  are  completely  overcome,  so  that  he  has 
neither  the  opportunity  to  show  them  nor  the  mind  to  use  them.  The 
ataxic  child,  in  playing  with  normal  children,  besides  tiring  more  quickly, 
being  outclassed,  becomes  bewildered  and  cannot  seize  the  opportunity 
to  attempt  coordinate  action. 

No  satisfactory  results  can  be  expected  from  the  treatment  of  ataxia 
unless  it  is  continued  until  the  child  is  able  to  play  as  well  as  other  chil- 
dren. The  treatment  should  be  made  practical  as  soon  as  possible. 
Do  not  spend  unnecessary  time  on  gymnastics  or  apparatus.  When  a 
child  shows  that  he  is  able  to  take  one  step,  begin  walking  exercises, 
going  up  and  down  stairs,  and  running. 

Study  the  patient's  movements,  and  analyze  his  defects  in  execu- 
tion. To  tell  a  child  not  to  fall  when  he  is  walking,  and  expect  him  to 
be  able  to  avoid  falling,  is  not  fair  to  the  child.  He  does  not  know  why 
he  falls,  and  his  attempts  to  avoid  it  only  increase  his  general  nerve 
tension.  His  falling  may  be  due  to  one  of  several  causes:  it  may  be 
that  he  is  walking  with  his  feet  widely  separated;  if  so,  he  gets  but  little 
support  from  the  advancing  foot,  and  upon  fatigue,  diverting  of  atten- 
tion, or  striking  a  small  obstacle,  he  will  fall.  When  he  permits  his  feet 
to  separate,  he  should  at  once  be  directed  to  keep  them  close  together. 
By  so  training  the  child  it  will  become  easier  to  keep  his  feet  in  position, 
and,  if  there  is  no  other  defect,  falling  will  unconsciously  be  avoided.  So 
all  of  his  work  must  be  analyzed  to  discover  its  weaknesses  or  defects. 

General  gymnastics  have  no  place  in  the  treatment  of  ataxia,  but 
where  certain  groups  of  muscles  are  weak,  movements  may  be  given  to 
strengthen  them,  in  order  that  they  may  do  their  part  in  coordination. 
Throughout  the  greater  part  of  the  treatment  I  have  used  exercises  for 


832  THE    PEACTICE    OF    PEDIATRICS 

strengthening  certain  groups  of  muscles,  although  their  primary  value 
was  not  to  improve  coordination.  It  is  well  to  have  these  movements 
executed  against  resistance,  in  order  to  determine  the  amount  of  muscu- 
lar power  the  patient  possesses. 

Coordinate  efforts  at  balancing  and  walking  are  first  made  upon 
the  floor  until  the  child  shows  a  little  improvement,  but  it  is  difficult 
to  make  a  child  realize  the  necessity  for  using  all  of  his  energies  in  the 
effort,  when  he  knows  that  there  is  no  particular  danger;  therefore  ap- 
paratus is  necessary  to  force  coordination.  Boards,  blocks,  and  ladders 
(see  Fig.  121)  are  used,  not  for  the  purpose  of  developing  ability  toper- 
form  exercises  upon  them,  but  to  develop  unconsciously  the  habit  of 
constant  care  a,nd  watchfulness,  as  the  child  can  readily  appreciate  the 
fact  that,  without  such  precaution,  he  will  slip  and  fall ;  and  also  learns 
that  he  cannot  relax,  whenever  he  is  inclined  to  do  so,  as  he  might  were 
he  on  the  floor.  By  this  apparatus  work,  children  unconsciously  ac- 
quire the  ability  to  control  themselves  in  places  of  danger  into  which 
their  play  leads  them. 

Always  place  some  incentive  before  the  child  as  otherwise  he  rarely 
puts  forth  the  necessary  exertion.  His  interest,  attention,  and  muscular 
and  nervous  energy  must  be  exerted.  Tell  him  that  it  is  necessary  to 
do  a  certain  amount  of  work  before  the  treatment  is  over;  that,  when  a 
certain  amount  is  done,  the  treatment  for  the  time  will  be  over,  whether 
the  hour  is  up  or  not.  Tell  him  that  he  must  do  something  more  than 
he  did  the  day  before,  whether  it  takes  longer  than  the  hour  or  not.  If 
it  takes  longer  than  the  hour,  he  will  learn  that  you  mean  what  you  say, 
and  sometimes  the  entire  work  of  the  hour  will  be  executed  in  the  last 
few  minutes,  despite  the  fact  that  the  fatigue  of  the  previous  efforts 
makes  it  more  difficult. 

While  we  wish  to  avoid  fatigue,  a  certain  amount  is  harmless.  If  a 
child  remains  fatigued  at  the  end  of  ^.n  hour's  rest,  following  the  treat- 
ment, and  he  does  not  coordinate  as  well  as  before  the  treatment,  pro- 
vision should  be  made  for  more  rest  during  the  next  treatment.  A 
child's  inertia  needs  to  be  overcome  in  spite  of  fatigue.  The  treatment 
will  teach  him  that  merely  saying  he  is  tired  will  not  enable  him  to  escape 
the  work.  This  has  been  impressed  upon  me  by  seeing  how,  after  fifty- 
five  minutes  of  unsuccessful  effort,  a  child  will  "pull  himself  together," 
as  it  were,  and  do  a  new  exercise  that  may  really  be  difficult,  in  order 
that  he  may  be  able  to  leave  at  the  end  of  the  hour. 

Never  permit  a  child  to  suffer  a  fall  or  injury  during  the  treatment. 
Never  take  any  risks  with  your  patient,  (See  Fig,  135,)  Falls  cannot 
be  prevented  in  ordinary  walking  or  running,  except  by  words  of  cau- 
tion, which  should  always  be  used;  however,  they  should  not  be  used 
in  tests  when  the  patient  is  endeavoring  to  see  how  far  he  can  walk  or 
run  before  he  falls.     On  the  first  fall,  make  him  return. 

Experience  teaches  a  patient  distrust  of  his  ability  to  do  a  thing 
which  he  has  never  tried,  or,  having  failed  after  several  trials,  he  will 
naturally  say  he  cannot  do  it,  and  not  wish  to  attempt  it.  Confidence 
must  be  inspired  in  him  to  follow  directions  unhesitatingly  by  insisting 


CONGENITAL   ATAXIAS 


833 


upon  his  accomplishing  every  task  given  him,  and  thus  proving  his  ability 
to  do  it,  and  also  by  showing  him  that  his  interest  is  yours,  and  that 
you  have  never  permitted  him  to  be  injured  during  his  unsuccessful 
attempts. 

With  a  child  it  is  not  enough  to  secure  coordinate  action,  but  you 
must  secure  endurance  along  the  lines  of  reflex,  coordinate  action.  Co- 
ordinate action  with  one  who  is  ataxic  calls  for  general  tension,  and  the 
unnecessary  accessory  action  of  groups  of  muscles  is  fatiguing,  and  re- 
sults in  excessive  waste  of  nerve  and  muscle  energy.  To  teach  a  child 
to  do  his  work  easily  and  to  carry  on  prolonged  coordinate  effort  is  thus 
accomplished  by  the  same  means.  A  parallel  can  be  found  in  a  person 
learning  to  skate  or  swim.     Here  we  have  a  general  tension  and  the  gen- 


Fig.  135. — Walking  on  a  narrow  board  several  feet  above  the  floor. 

exercise  in  coordination. 


An  advanced 


eral  action  of  all  the  muscles  of  the  body— a  great  waste  of  energy  to 
prevent  one  from  falling,  or  going  under  the  water — and  even  after  one 
has  learned  how  to  swim,  much  of  that  nervous  waste  of  energj^  will  con- 
tinue until  he  has  thoroughly  mastered  the  art.  Endurance  and  con- 
servation of  energy  are  very  desirable  in  an  ataxic. 

After  he  had  been  in  training  for  several  months  one  patient  walked 
forward,  without  stopping,  five  hundred  feet  on  the  top  of  a  fence,  and 
backward  one  hundred  and  twenty  feet  without  stopping.  The  same 
child  walked  several  miles  up  and  down  a  mountain-side  ^vithout  stop- 
ping, his  mind  occupied  with  observation  and  not  applied  at  all  to  his 
walking,  save  in  response  to  caution.  He  was  able  also  to  run  half  a 
mile  without  stopping  or  falling.  It  is  not  for  the  purpose  of  making 
53 


834  THE    PRACTICE    OF   PEDIATRICS 

the  child  a  long-distance  walker  or  runner  that,  after  he  has  learned  to 
walk  or  run  properly,  the  distance  is  gradually  increased  to  one  or  more 
miles,  telling  him  to  'Hake  it  as  easy  as  possible"  without  stopping, 
although  when  fatigue  is  noticed  sufficient  rest  should.be  given.  It  is 
common  to  see  normal  children  of  three  or  four  years  of  age  run  and  play 
for  long  periods  of  time  without  apparently  tiring — our  object  in  en- 
durance exercises  is  to  fit  the  patient  for  a  child's  sphere  in  life.  Grad- 
ually the  muscles  become  inured  to  fatigue,  do  their  work  with  a  mini- 
mum expenditure  of  force,  and  to  a  certain  extent  recuperate  while  in 
action. 

Short  periods  of  retrogression  must  be  expected  occasionally  through- 
out the  entire  course.  When  a  child  is  tired,  has  had  excitement,  or 
when  he  is  indisposed,  one  must  expect  a  temporary  loss  of  coordination. 
Parents  too  should  be  prepared  for  this,  and  not  be  disheartened  when 
it  occurs. 

The  life  of  an  ataxic  child  should  be  quiet  and  free  from  excite- 
ment. Judgment  should  be  used  in  allowing  him  to  mingle  with  other 
children,  even  though  they  are  members  of  his  own  family.  When 
allowed  to  play,  it  should  be  with  younger  children,  if  possible,  or  with 
his  nurse,  or  mother,  until  the  time  of  playing  with  other  children  is 
made  a  part  of  the  treatment,  and  even  then  it  should  be  confined  to 
fines  permitted  by  the  one  in  charge.  In  the  intervals,  a  child  needs 
sufficient  quiet  and  rest,  so  that  he  will  completely  recuperate  and  be 
in  the  best  possible  condition  for  the  next  treatment,  as  the  treatments 
afford  the  only  hope  of  restoring  him  to  nerve  stability  and  normal  mus- 
cular movement.  As  he  improves,  however,  the  daily  regime  should 
vary.  As  a  rule,  a  child  should  rest,  lying  down  from  one-half  hour  to 
an  hour  before  treatment,  and  the  same  length  of  time  after  treatment, 
and,  in  fact,  at  any  time  during  the  day  when  incoordination  becomes 
marked. 

Attention  to  the  general  health  of  the  child  is  important.  There 
should  be  a  simple  and  nutritious  diet,  careful  attention  to  the  bowels, 
daily  bathing,  an  outdoor  fife,  the  treatment  being  taken  whenever  possi- 
ble in  the  open  air.  These  things  should  not  be  neglected,  as  these  pa- 
tients are  apt  to  have  less  resistance  to  disease  than  non-ataxic  children. 

Illness  does  not  cause  a  retrogression  except  temporarily  through 
the  weakness  which  follows  it.  With  returning  health  and  strength, 
progress  continues. 

Cooperation  is  important.  It  is  more  necessary  here  than  in  any 
other  chronic  ailment.  A  child  will  recover  in  one-half  the  time  if  co- 
operation is  conscientiously  given  by  those  in  charge  of  the  child.  For 
illustration:  the  child  is  capable  of  walking,  but  walks  on  the  balls  of 
his  feet,  or  crosses  his  feet  frequently,  which  causes  him  to  lose  his 
balance  easily;  whenever  he  does  it,  if  he  is  called  back,  no  matter  what 
his  object  may  be  for  going,  until  he  has  walked  across  the  floor  correctly, 
the  next  time  he  starts  to  walk  it  will  not  be  necessary  to  call  him  back  as 
many  times,  and  the  constant  correct  walking  will  gradually  make  it  a 
reflex  habit.     If  he  is  permitted  to  walk  incorrectly,  it  encourages  inco- 


CONGENITAL   ATAXIAS  835 

ordination  and  a  careless  habit.  The  course  of  nervous  stimuli  has  been 
likened  to  the  making  of  a  new  path  in  a  jungle.  Constant  use  will  make 
it  easy  to  travel,  but  if  the  old  path  of  incoordination  is  used  instead, 
the  new  path  of  coordination  remains  a  difficult  task  for  a  much  longer 
period  of  time.  The  lines  of  least  resistance  are  followed,  and  the  new 
path  must  be  made  as  easy  as  the  old  if  we  would  have  a  child  use  it. 

Treatment  should  be  for  an  hour  daily.  More  than  an  hour's  treat- 
ment is  apt  to  produce  general  nervous  fatigue.  An  ataxic  child  may 
need  training  along  many  lines,  and  the  attempts  to  do  one  thing  cor- 
rectly may  require  so  long  a  time  that  it  is  unwise  to  attempt  to  give 
work  for  the  correction  of  all  at  one  treatment.  If  this  is  attempted, 
nothing  will  be  well  done  in  the  hour,  and  the  work  will  only  serve  to 
tire  the  patient  and  increase  the  incoordination.  It  would  take  a  normal 
person,  who  could  do  the  movements  well,  more  than  one  hour  to  cover 
all  the  lines  with  improvement  in  each.  An  hour  has  been  spent  in 
endeavoring  to  walk  a  plank  once  without  falling  off,  but  the  child  did 
it  before  the  treatment  was  completed,  and  the  next  day  he  did  it  twice, 
so  there  was  evident  progress.  When  one  morning  hour  is  given  to  the 
lower  limbs,  work  might  be  mapped  out  so  that  an  assistant,  the  mother 
or  nurse,  could  give  another  hour,  or  half  hour,  in  the  afternoon  to  ex- 
ercises for  the  arms  and  fingers,  or  to  massage,  which  would  improve  the 
nutrition  of  the  tissues  and  the  general  circulation,  so  as  to  insure  a 
better  general  response  of  the  nerves  and  muscles.  Another  half-hour 
could  be  spent  in  training  the  speech  of  the  child.  In  this  way  the  cor- 
rection of  the  upper  limbs  and  speech  could  progress  at  the  same  time 
as  that  of  the  lower  limbs,  instead  of  waiting  until  after  the  coordination 
in  the  lower  limbs  is  first  secured. 

Improvement  in  one  line  does  not  imply  any  special  improvement 
in  another.  Walking,  running,  going  up  and  down  stairs,  jumping,  and 
hopping  must  each  be  taken  up  separately.  It  is  particularly  true,  in 
case  one  is  working  for  improvement  in  the  lower  limbs,  and  little  at- 
tention is  given  at  the  same  time  to  the  upper.  At  the  end  of  the  time 
devoted  to  locomotion,  the  ataxia  of  the  upper  limbs  is  but  little  im- 
proved. 

Parents  and  physicians  occasionally  think  that  a  child  v/ill  outgrow 
his  ataxia,  but  this  is  a  mistake. 

A  patient  should  hold  as  good  a  posture  as  possible  at  all  times,  as 
the  weight  of  the  body  is  then  better  adjusted.  One  or  two  exercises 
under  Posture  should  be  added  to  the  treatment.  The  suggestions  about 
clothing,  under  Posture  (p.  807),  are  especially  valuable  here. 

Five  or  ten  minutes  once  or  twice  a  day  should  be  devoted  to  a  sit- 
ting posture  in  which  the  body  is  held  erect,  but  the  limbs  relaxed,  and 
every  part  of  the  body  entirely  at  rest.  This  aids  greatly  in  overcoming 
the  nervous  instability  and  irritability,  and  is  a  valuable  help  in  securing 
general  nervous  control. 

When  the  patient  is  given  his  treatment  there  should  be  no  one  else 
in  the  room,  unless  it  is  one  whose  presence  would  aid  in  securing  better 
attention  or  work  from  the  child. 


836  THE    PRACTICE    OF   PEDIATRICS 

There  is  a  difference  in  the  treatment  of  congenital  ataxias  and  that 
of  locomotor  ataxia:  In  one  case  the  patient  is  a  child,  in  the  other  an 
adult.  With  the  child,  between  treatments  there  is  little  or  no  coopera- 
tion; with  an  adult  there  is  cooperation.  During  the  period  of  develop- 
ment a  child's  sphere  is  that  of  play  and  muscular  activity.  The  adult 
looks  forward  only  to  retm^ning  to  his  business  or  professional  activity, 
and  stops  treatment  when  his  proficiency  and  coordination  permit  this. 
Exercises. — In  the  begiiming,  when  the  child  cannot  walk,  exercises 
should  be  taken  while  lying  down.  For  the  lower  limbs,  they  consist 
of  coordinate  flexions  and  extensions,  abductions,  adductions,  and  cir- 
cumductions, actively  and  against  resistance,  and  of  touching  certain 
designated  points  or  objects  with  the  feet  separately.  In  cerebellar 
ataxia  one  can  more  readily  advance  to  the  standing  exercises,  and  take 
foot-placings  (floor  may  be  marked  for  this),  stepping  out  to  side,  front 
and  back  to  the  ordinary  oblique  positions,  forward  and  backward. 
The  weight  of  the  body  is  carried  by  the  advancing  foot,  so  that  when 
the  movement  is  completed  the  weight  rests  equally  over  both  feet. 
Taking  a  step  is  now  practised,  bringing  up  the  other  foot  to  the  side  of 
the  foot  advanced.  This  is  done  sideways,  forward,  and  backward. 
Two  or  three  steps  are  now  attempted,  a  pause  being  made  after  each 
one  until  a  perfect  poise  of  the  body  is  obtained.  This  is  continued  until 
the  child  can  walk  across  the  room.  At  this  time  the  defects  shown  in 
the  walking  should  receive  attention. 

The  defects  in  walking  or  running  are  usually  the  following:  carry- 
ing the  weight  of  the  body  too  far  forward;  not  straightening  the  knees 
completely;  the  reeling  gait;  the  crossing  of  the  legs;  walking  with  the 
feet  separated;  turning  the  toes  inward;  not  lifting  the  feet  sufficiently; 
not  bringing  the  heels  to  the  ground.  As  occasion  arises,  show  the  child 
his  defects,  and  caution  him  against  their  repetition.  In  walking  and 
running  in  the  room,  repeat  the  exercise  if  any  faulty  execution  is  noted. 
Instruct  the  members  of  the  household,  who  have  charge  of  the  child, 
never  to  ignore  these  defects,  but  always  to  insist  upon  their  immediate 
correction.  In  the  outdoor  walking  or  running,  the  patient  should 
always  be  in  advance  of  you,  so  that  his  every  movement  may  be  ob- 
served. It  is  here  that  the  correction  of  the  defects  should  mainly  take 
place.  The  following  four  movements  aid  in  correction,  and  should 
be  given  every  day  for  quite  an  extended  period,  in  order  that  the  weak- 
ened muscles  may  be  strengthened  for  the  required  work  of  coordination: 

(a)  Drawing  up  the  knees  against  resistance. 

(6)  Flexing  the  feet  against  resistance. 

(c)  Abduction  of  feet  against  resistance. 

{d)  Extension  of  legs  against  resistance. 

In  the  full  extension  of  the  legs,  the  feet  must  be  kept  flexed. 

When  the  child  is  able  to  walk  across  the  room,  work  is  begun  upon 
the  apparatus:  boards  from  7  inches  down  to  1  inch  in  width  by  half 
an  inch  in  thickness  and  10  feet  in  length,  of  well-seasoned  hard  wood; 
a  ladder,  the  sides  of  which  are  13^  by  23^  inches,  10  feet  in  length,  and 
the  rounds  %  inch  in  diameter  by  12  inches  long,  placed  10  inches  apart 


CONGENITAL   ATAXIAS  837 

in  the  ladder;  24  blocks  of  wood,  2  inches  in  thickness  and  12  inches 
wide  by  14  inches  long.  Beginning  with  the  7-inch  board,  have  the 
child  walk  over  and  back,  with  the  arms  in  different  positions,  the  eyes 
open  and  the  eyes  shut;  one  end  of  the  board  placed  upon  one  block, 
and  so  on  until  one  end  is  resting  upon  ten  or  more  superimposed  blocks. 
The  board  is  placed  upon  supports  of  equal  height,  beginning  wdth  one 
block  under  each  end,  increasing  the  height  until  the  board  is  about 
five  feet  from  the  ground.  At  each  increase  in  height  the  various  ex- 
ercises are  repeated.  (See  Fig.  136.)  Two  five-inch  boards  can  be  used 
when  placed  upon  the  same  supports,  the  boards  being  about  eight  or 
ten  inches  apart.  The  child  can  step  from  one  board  to  the  other,  going 
from  one  end  to  the  other;  and,  standing  in  the  center,  he  can  step  for- 
ward and  backward  from  board  to  board.  With  boards  placed  together, 
walk  forward  and  backward,  the  boards  bending  unevenly  as  one  foot  is 
on  each  board. 

Using  the  blocks  alone,  arrange  them  for  walking,  at  varying  dis- 
tances from  each  other;  also  make  piles  uneven  in  height,  and  have 
patient  walk  on  the  blocks  with  the  eyes  open  and  the  eyes  shut. 

Ladder  Exercises. — Ladder  flat  on  the  ground,  walk  forward  in  the 
spaces  between  the  rounds;  walk  sideways  and  walk  backward.  Place 
one  end  of  the  ladder  upon  a  block  and  add  blocks  gradually  until 
the  ladder  reaches  the  height  of  the  child's  knee;  then  begin  with  both 
ends  of  the  ladder  placed  on  single  blocks,  gradually  increasing  the  height 
until  the  ladder  reaches  the  height  of  the  knee;  after  each  change  of 
height  the  walking  exercise  forward,  sideways,  and  backward  is  repeated. 
When  using  the  blocks  the  child  may  bring  them  from  the  pile  and  build 
the  steps  that  he  is  to  walk  upon;  standing  upon  the  block  previously 
placed  upon  the  floor,  he  bends  forward,  placing  in  position  the  one  he 
carries,  repeating  the  process  until  all  the  blocks  are  arranged.  When 
through  walking  over  the  blocks,  he  stands  on  the  one  next  to  the  last 
one  placed,  bends  over  and  picks  up  the  last  one,  and  may  carry  it  back 
to  the  pile,  walking  over  the  blocks,  or  he  may  lift  and  raise  it  above  the 
head,  and  pass  it,  either  forward  or  backward,  to  you.  The  block  may 
be  carried  by  the  child  walking  through  the  spaces  of  the  ladder,  and 
both  ladder  and  blocks  may  be  arranged  in  various  forms  to  be  walked 
over  by  the  child. 

You  may  now  take  up  the  balancing  work,  where  the  weight  of  the 
body  is  carried  on  only  a  portion  of  the  sole  of  the  foot,  as  in  walking 
on  the  rounds  of  the  ladder.  The  ladder  is  first  placed  flat  upon  the 
ground,  and  the  walking  is  done  forward  and  backward.  This  is  graded 
by  raising  one  end  of  the  ladder  until  the  child  can  walk  up  and  dowTi 
on  the  rounds  several  times  without  a  mistake,  the  ladder  raised  to  an 
angle  of  35  degrees.     (See  Fig.  136.) 

In  beginning  the  treatment,  the  child  is  instructed  not  to  allow 
one  foot  to  step  directly  in  front  of  the  other.  By  this  time  coordination 
is  sufficiently  mastered  so  that  balancing  as  an  exercise  may  be  taken  up, 
using  the  boards  from  2  inches  down  to  one  inch  in  width.     On  these 


838 


THE   PRACTICE    OF   PEDIATRICS 


boards  the  child  must  place  one  foot  in  front  of  the  other,  and  walk  for- 
ward across  it;  next,  walk  backward,  eyes  open  and  eyes  shut. 

When  a  child  is  able  to  walk  50  or  60  feet  without  falling  or  stopping 
to  rest,  the  distance  is  gradually  increased  in  outdoor  walks,  correcting 
defects  when  noticed,  until  he  can  walk  a  mile  or  more  without  their 
occurrence  or  without  falling. 


Fig.  136.- 


-  Walking  on  rounds  of  ladder,  one  end  raised  several  feet  above  floor — an 
advanced  exercise  in  coordination. 


When  the  patient  is  able  to  run  across  the  room  in  a  straight  hne, 
teach  running  in  a  circle.  Watch  closely  his  running  and  do  not  allow  the 
feet  to  be  widely  separated,  or  the  weight  of  the  body  to  incline  too  much 
forward.  He  should  run  with  a  firm  stride  and  raise  his  feet  well.  In- 
crease distance  until  he  can  run  half  a  mile  without  falling  or  stopping  to 
rest.  Later,  teach  running  up  and  down  hill;  running  short  distances,  as 
from  80  to  100  feet,  as  fast  as  he  can,  and  stopping  without  falling;  trying 
to  catch  a  person;  racing  with  another  child,  who  starts  at  a  sufficient 


CONGENITAL   ATAXIAS  839 

distance  behind  him,  so  that  they  will  finish  at  about  the  same  time ;  run- 
ning to  catch  a  person  who  will  dodge  and  run  zigzag  and  in  circles, 
playing  with  other  children  in  rmming  games,  such  as  "cross-tag," 
"pull  away,"  etc.,  having  the  other  children  so  handicapped  that  by 
exerting  himself  to  the  utmost  he  will  not  be  caught.  During  these 
games,  if  he  falls,  he  should  be  obliged  to  run  around  the  grounds  once 
alone. 

Other  indoor  exercises  are:  whirling  on  one  foot  50  times  without 
falling;  repeat  on  the  other  foot;  alternate  thus  with  eyes  open  and  eyes 
shut;  running  in  a  short  circle  50  times  without  falling.  Such  exer- 
cises are  helps  to  the  running  out-of-doors.  Another  helpful  exercise 
is  running  several  hundred  feet  out-of-doors,  whirling  around  in  the 
direction  indicated  without  falling  whenever  the  command  "turn  right," 
or  "turn  left,"  is  given. 

Walking  Up  and  Down  Stairs. — Begin  with  one  or  two  steps  and 
gradually  increase  until  the  length  of  the  flight  is  reached,  seeing  that 
the  feet  are  not  separated,  but  that  they  advance  in  straight  fines  di- 
rectly in  front  of  the  body.  In  walking  up  stairs,  carry  the  weight  of 
the  body  over  the  foot  that  is  on  the  upper  stair.  In  walking  down. 
stairs,  be  sure  that  the  heel  is  brought  against  the  back  of  the  stair,  so 
that  the  foot  at  no  time  will  rest  on  the  edge.  Keep  the  hands  close  to 
the  sides  of  the  body  while  walking  up  and  down  stairs  with  the  eyes 
shut.  Run  up  and  down  stairs  with  the  eyes  open  and  again  vnih  eyes 
shut,  carrying  articles  while  running.  One  should  always  be  near 
enough  to  the  child  for  his  protection  in  case  of  accident.  The  object 
is  to  train  the  muscular  sense  and  make  the  coordination  sufficiently 
reflex  to  enable  the  child  to  run  or  walk  up  the  stairs  alone  ^\'ithout 
the  danger  of  an  accident. 

Jumping. — Draw  a  line  with  a  piece  of  chalk;  teach  the  child  to 
incline  his  body  slightly  forward,  bending  knees  a  fittle,  spring  forward, 
aided  by  an  upward  swing  of  his  arms.  Jump  for  height  and  distance 
over  the  rounds  of  the  ladder,  from  one  space  to  another,  and  repeat, 
skipping  one  space.  Jump  from  block  to  block,  the  blocks  being  sepa- 
rated at  varying  distances.   Jumping  over  blocks;  rmming  and  jumping. 

Hopping. — Hopping  is  much  more  difficult,  as  the  spring  is  from 
one  foot  alone,  and  the  landing  on  the  same  foot.  In  addition  to  the 
coordination  necessary  to  balance  upon  one  foot,  are  added  the  required 
effort  to  lift  the  body  from  the  ground  and  the  coordination  required 
for  balancing  the  body  on  landing,  so  as  to  avoid  falfing.  The  training 
is  about  the  same  as  in  jumping;  hopping  with  either  foot  over  a  string; 
hopping  for  distance;  hopping  for  height;  and  making  a  succession 
of  hops  on  the  same  foot,  without  touching  the  other  foot  to  the  gTouud; 
the  running  hop. 

At  the  close  of  these  exercises  it  may  not  be  amiss  to  repeat  what 
was  stated  at  the  beginning,  that  it  is  not  desired  to  make  the  child  an 
athlete,  but  distance  walking,  distance  running,  fast  rmming,  jumping, 
and  hopping  are  exercises  which  children  use  in  their  play  for  long  pe- 
riods of  time,  and  the  coordination  secured  by  the  apparatus  work  is 


840  THE    PRACTICE    OF   PEDIATRICS 

often  of  value  in  places  of  danger,  where  their  play  is  often  apt  to  lead 
them.     Coordination  to  this  degree  should  be  secured. 

Exercises  for  the  Upper  Limbs. — In  the  beginning,  the  general  move- 
ments of  the  fingers,  wrists,  forearms,  upper  arms,  and  shoulders  may- 
be practised,  executing  them  slowly  until  the  coordination  is  perfect  in 
these  movements.  The  above  exercises  are  simple  movements  of  flexion, 
extension,  rotation,  and  circumduction.  The  educative  movements, 
however,  have  mainly  to  do  with  the  fingers : 

1.  Flexing  and  extending  the  fingers. 

2.  Slowly  and  gently  touch  the  tip  of  the  thumb  to  the  tip  of 
each  finger  and  hold  them  together  without  pressure  while  five  is 
counted. 

3.  Simultaneously  touch  the  tip  of  each  finger  to  the  tip  of  the 
thumb. 

4.  Flex  strongly  the  index-finger  so  that  the  end  will,  touch  the  base 
of  its  second  metacarpal  bone. 

5:  Flex  strongly  and  adduct  the  thumb  so  that  the  tip  of  the  thumb 
will  press  the  tip  of  the  little  finger. 

6.  Flex  strongly  and  adduct  the  thumb  so  that  its  tip  will  press  the 
base  of  the  little  finger. 

7.  Needles:  have  them  graded  from  the  largest  to  the  smallest  size, 
grasp  a  fine  thread  between  thumb  and  each  finger  of  one  hand  in  turn, 
and  thread  each  needle;  repeat,  using  the  other  hand. 

8.  Buttons:  have  them  graded  from  the  largest  to  the  smallest  ob- 
tainable, and  have  them  sewed  on  to  one  strip  of  cloth,  another  strip 
of  cloth  having  buttonholes  to  correspond.  Practise  buttoning  and  un- 
buttoning with  thumb  and  index-finger  of  each  hand. 

9.  Pins:  picking  them  up  with  fingers.  "Pick  up  the  pins  and  press 
them  through  a  stiff  pasteboard  box,  forming  various  designs. 

10.  With  a  pencil  correctly  held,  make  squares,  triangles,  parallel 
lines,  etc.,  with  and  without  dots  as  a  guide. 

11.  With  a  pencil  correctly  held,  make  figures  and  letters,  both  large 
and  small. 

The  child  can  also  use  the  exercises  of  piling  coins  and  chips,  touch- 
ing hanging  balls,  placing  pegs  in  holes,  and  similar  games.  Also  throw- 
ing and  catching  a  ball.  A  child  should  be  made  to  dress  and  undress 
himself,  and  to  feed  himself,  although  as  exercises,  at  the  beginning,  he 
may  do  them  only  in  part. 

In  eating,  the  spoon  or  fork  should  never  be  full,  and  the  cup  or  glass 
should  be  only  partly  filled.  The  execution  of  the  movements  should 
be  slow. 

For  incoordination  of  the  neck  muscles  (more  often  a  part  of  choreic 
ataxia)  the  shot-bag  exercises  (p.  811)  are  of  value.  They  should  be 
preceded  by  a  course  of  simpler  exercises. 

Exercises  for  the  Speech. — A  child  should  be  taught  to  enunciate 
numbers  and  letters  distinctly.  An  interesting  book  should  be  read 
to  him,  reading  one  or  more  words  at  a  time,  and  requiring  him  to  repeat 
them  correctly  after  you. 


ANTERIOR   POLIOMYELITIS  841 

Friedreich' s  Disease. — In  a  well-marked  case,  begin  treatment  with 
massage  to  improve  the  nutrition  of  the  weakened  and  atrophied  mus- 
cles and  to  help  relax  the  spasm  in  the  contracted  muscles.  In  con- 
nection with  the  massage,  passive  exercise  of  the  limbs  is  given  and 
gradual  and  persistent  extension  is  made  upon  the  contractures,  en- 
deavoring to  gain  a  Httle  each  day  until  the  hmbs  are  fully  extended; 
then  increase  from  day  to  day  the  time  during  which  the  limb  is  held 
at  full  extension  and  abduction.  The  degree  of  motion  in  the  joints 
is  utihzed  by  giving  active  movements.  In  order  that  the  muscles  may 
become  stronger,  slight  resistance  is  given  to  these  movements,  and 
greater  attention  paid  to  the  strengthening  of  the  weaker  groups  of 
muscles.  When  the  muscles  have  moved  the  limbs  as  far  as  possible, 
the  extension  must  be  completed  by  stretching  or  by  pressure.  A  child 
should  be  taught  how  to  turn  over,  after  pushing  up  his  arms  out  of  the 
way.  When  lying  prone  he  should  try  to  draw  up  his  knees  under  his 
body,  and  when  his  arms  become  flexible  enough  and  strong  enough, 
he  should  raise  up  his  body  until  he  rests  on  his  hands  and  knees;  later 
he  is  required  to  raise  himself  until  he  is  sitting  upon  his  legs,  which  are 
flexed  underneath  his  thighs.  Have  patient  raise  his  body  from  a 
reclining  to  a  sitting  posture,  with  legs  extended.  Let  him  sit  in  a 
chair  which  is  low  enough  to  permit  him  to  place  his  feet  upon  the  floor, 
but  without  any  supporting  arms.  Let  him  rise  from  a  sitting  to  a 
standing  posture  by  drawing  back  his  feet  underneath  him,  and  inclining 
his  body  shghtly  forward,  then  straightening  up  to  a  standing  posture. 
Have  him  balance,  upon  standing,  from  a  few  seconds  to  several  minutes, 
stretching  his  body  up  to  its  full  height.  Give  foot-placings,  then  let 
him  attempt  a  few  steps,  pausing  after  each  step  to  strengthen  up, 
balance,  and  "make  himself  tall."  From  this  point  the  treatment  is 
the  same  as  that  of  the  ataxia  of  the  cerebellar  type,  except  that  the 
massage  and  work  for  overcoming  the  contractures  must  be  continued 
indefinitely,  or  the  progress  will  be  slower. 

ANTERIOR  POLIOMYELETIS 

Exercises  should  include  action  of  all  the  groups  of  muscles  of  the 
limbs.  The  exercise  of  the  muscles  that  are  normal,  or  but  little  im- 
paired, stimulates  the  nutrition  of  the  neighboring  impaired  muscles. 

With  the  patient  in  a  reclining  position  the  thighs  may  be  flexed, 
extended,  abducted,  adducted,  and  circumducted  against  resistance 
when  possible.  The  leg  may  be  flexed  and  extended,  and  the  foot  may 
be  flexed,  extended,  abducted,  and  circumducted.  These  movements 
may  be  passive  at  first;  later,  when  possible,  they  may  also  be  taken 
standing.  Flexion  and  abduction  of  the  foot  and  extension  of  the  toes 
are  results  which  will  come  last. 

A  faint  response  is  sometimes  seen  after  friction  over  the  superficial 
points  of  the  nerves  supplying  these  muscles,  or  when  the  limb  is  im- 
mersed in  hot  water,  and  when  this  response  is  seen  the  movements 
should  be  completed  passively.  As  the  muscles  show  signs  of  returning 
functions,  the  movements  are  repeated  frequently  during  the  day,  but 


842  THE    PRACTICE    OF   PEDIATRICS 

alwaj' s  stopped  when  the  responsive  motion  becomes  weaker,  in  order 
that  fatigue  may  be  avoided.  When  possible,  the  hghtest  resistance 
should  be  given,  so  that  the  power  of  the  muscles  may  be  better  ascer- 
tained, and  their  work  thus  gradually  increased  by  increasing  the  re- 
sistance. An  added  stimulus  may  be  given  by  having  the  normal  hmb 
execute  the  movement  with  the  paralyzed  hmb.  Occasionally,  move- 
ment is  secured  in  all  but  one  toe.  Where  there  is  improvement  in  any 
way  in  the  paralyzed  hmb  the  treatment  should  be  continued,  for  cases 
have  shown  that  muscles  may  respond  to  treatment  even  though  there 
may  be  no  faradic  reaction  for  more  than  a  year. 

When  the  patient  is  able  to  walk,  walking  and  marching  exer- 
cises should  be  taken  up,  such  as  walking  on  straight  lines  to  and  from 
certain  objects,  walking  on  the  toes,  walking  with  the  arms  sideways 
shoulder  high,  and  with  arms  in  a  vertical  position.  The  blocks, 
boards,  and  ladder  that  are  used  in  treating  ataxic  patients,  previously 
described,  are  of  use  here.  The  use  of  a  trough  or  of  a  narrow  ladder  with 
sides  6  or  8  inches  in  width  serves  to  help  the  patient  overcome  the  out- 
ward throw  of  the  paralyzed  leg.  Although  the  dimensions  of  the  ladder 
are  different,  the  walking  exercises  outlined  in  the  treatment  of  ataxia  may 
be  followed  in  part.  In  walking,  the  patient  should  endeavor  to  keep  the 
foot  flexed  as  much  as  possible,  touching  the  heel  first  in  bringing  down 
the  foot.  The  following  may  also  be  given :  walking  on  the  heels  for  a 
short  distance;  jumping;  climbing  a  ladder,  using  hands  and  feet;  running 
(but  do  not  permit  an  outward  throw  of  the  paralyzed  leg — it  must 
advance  straight  forward);  hanging  from  a  bar,  swinging  both  legs 
forward,  sideways,  and  backward,  keeping  heels  together,  and  with  feet 
apart.  A  Hght  basket-ball  or  foot-ball  may  be  used  for  kicking.  Have 
patient  practise  the  drop-kick,  and  show  you  how  hard  he  can  kick. 

Exercises  for  the  Arms. — Flexion,  extension,  abduction,  adduction, 
and  circumduction  of  the  upper  arm;  flexion,  extension,  and  rotation 
for  the  forearm  and  wrist,  with  and  without  resistance.  Have  patient 
close  hand  as  tight  as  possible,  showing  how  hard  he  can  strike.  Have 
him  catch  a  basket-ball  and  practise  throwing  it  into  a  high  basket  at 
different  distances.  Drop  a  tennis-ball  into  his  hands  to  catch;  also 
toss  and  bound  it  for  him  to  catch.  Have  him  throw  a  tennis-ball  for 
height  and  distance.  The  tendency  is  to  throw  the  ball  downward. 
Some  of  the  special  finger  movements  used  in  the  treatment  of  ataxia, 
such  as  approximating  the  tip  of  the  thumb  and  the  tips  of  the  fingers, 
the  button  exercise,  the  work  with  the  pencil,  etc.,  may  also  be  given. 

Passive  Exercises. — ^Where  there  is  any  tendency  to  contracture 
in  the  groups  of  muscles  not  paralyzed,  or  in  which  the  degree  of  paralysis 
is  only  slight,  passive  exercises  should  be  given  to  secure  a  normal  range 
of  motion  of  the  contracted  groups  either  in  leg  or  arm.  This  must  be 
kept  up  throughout  the  treatment  for  the  purpose  of  lessening  or  over- 
coming the  tendency  to  deformity.  Care  should  be  used,  however,  in 
not  carrying  the  passive  motion  beyond  the  normal  range. 

Resistance  apphed  to  movements  of  contracted  muscles  serves  to 
stretch  them  more  than  does  the  passive  stretching. 


CONSTIPATION  843 

Massage. — Gentle,  deep  kneading,  light  clapping,  and  hacking 
friction  over  the  superficial  points  of  the  nerves  and  general  friction 
should  be  given  to  the  entire  hmb. 

Light  hacking,  vibration,  and  deep  kneading  should  be  given  to 
the  spinal  muscles. 

Fifteen  minutes  of  massage  should  be  given  once  or  twice  daily  as 
long  as  the  treatment  is  needed. 

CONSTIPATION 

In  addition  to  the  measures  suggested  in  a  previous  section  (page 
236)  for  the  rehef  of  constipation,  gymnastic  exercises  may  be 
brought  into  use. 

These  exercises  are  given  with  two  objects  in  view:  one,  to  strengthen 
the  abdominal  walls,  which  mechanically  stimulate  the  intestine;  the 
other,  to  stimulate  the  general  circulation,  which  quickens  the  portal 
circulation  and  increases  the  activity  of  the  liver. 

The  first  five  exercises  are  taken  from  a  reclining  position. 

1.  The  knees  straight  and  feet  extended.  Raise  both  legs  until 
they  are  at  a  right  angle  with  the  body. 

2.  Knees  straight.  Raise  heels  about  four  inches  above  couch; 
separate  them  as  widely  as  possible;  bring  them  together,  and  lower 
to  couch. 

3.  Kiiees  straight.  Raise  heels  ten  or  fifteen  inches  above  the 
couch.  Draw  up  the  knees  as  close  to  the  chest  as  possible,  without 
raising  heels.  Extend  the  legs  without  raising  or  lowering  the  feet. 
Lower  legs  to  couch. 

4.  Feet  held,  or  secured  by  strap.  Raise  body  to  sitting  position 
without  use  of  hands.  The  hands  may  be  placed  upon  the  thighs, 
folded  upon  the  chest,  placed  back  of  neck,  or  the  arms  may  be  extended 
beyond  the  head.  Changing  the  position  of  arms  in  the  order  named 
increases  the  exertion. 

5.  Feet  held.  Circle  trunk  sideways,  forward,  sideways,  back- 
ward to  the  starting  position,  starting  to  right  and  left  alternately. 
Arms  position  as  in  number  four. 

6.  Hang  from  bar  or  round  of  ladder.  Execute  No.  L  (The  posi- 
tion of  body  changed,  but  the  relation  of  legs  to  body  same  as  in  No.  1.) 

7.  Hanging  position.     Execute  No.  2. 

8.  Hanging  position.     Execute  No.  3. 

9.  Hanging  position.  Heels  together,  swinging  legs  from  waist, 
describe  as  large  a  circle  as  possible  with  the  feet. 

Each  of  the  above  exercises  may  be  followed  by  a  deep-breathing 
exercise. 

In  a  weak  patient,  the  detail  of  straight  knees  need  not,  at  first, 
be  insisted  upon.  If  necessary,  the  patient  may  be  assisted,  the  weight 
of  the  legs  or  body  being  partly  supported  until  the  patient  is  strong 
enough  to  execute  the  movement  alone. 

10.  Sitting  on  chair  or  stool.  Hands  placed  back  of  neck,  twist 
body  right  and  left  against  resistance. 


844  THE  PRACTICE  OF  PEDIATRICS 

11.  Sitting  position.  Hands  back  of  neck,  bend  body  right  and 
left  against  resistance. 

Exercises  for  the  General  Circulation. — Taken  from  a  standing 
position: 

1.  Bend  trunk  forward,  touch  floor  with  fingers,  keeping  the  knees 
straight. 

2.  Take  a  long  step  forward,  bend  the  forward  knee;  bend  trunk 
forward;  touch  the  floor  with  fingers.  Raise  trunk,  step  back  to  posi- 
tion.    Alternate  feet  in  stepping. 

3.  Stand  with  feet  two  foot-lengths  apart.  Raise  arms  sideways 
to  shoulder  height.  Bend  right  knee  and  bend  trunk  to  right  side, 
touching  floor  with  right  hand.     Raise  body.     Same  to  left. 

4.  "Chopping."  Stand  with  feet  separated,  fingers  interlaced. 
Bend  body  forward,  swinging  hands  to  floor  between  feet.  Raise 
body,  s\\dnging  hands  up  over  right  shoulder,  at  same  time  twisting 
to  right.     Swing  to  floor.      Same  to  left. 

5.  Hop,  feet  apart,  then  together,  quickly. 

6.  Run  in  place — i.  e.,  without  advancing. 

(a)  With  front  of  thighs  kept  in  same  plane  with  front  of  body, 
heels  striking  buttocks  in  running. 

(6)  With  each  step  in  running,  raise  the  knees  as  high  as  possible 
in  front  of  body. 

The  running  and  hopping  should  be  done  quickly,  and  continued 
long  enough  to  get  the  body  thoroughly  warm. 

Passive  Exercises. — 1.  Trunk-rolling.  Patient  in  a  sitting  position, 
feet  separated  and  fixed.  Grasp  him  by  the  shoulders,  and  with  a 
continuous  movement  bend  the  body  to  the  right,  forward,  left,  back 
to  the  starting  position.  After  the  movement  has  been  given  several 
times,  reverse  the  direction. 

2.  Thigh-rolling.  Patient  in  a  semi-reclining  position.  Grasp 
patient's  foot  with  right  hand,  his  leg  just  below  the  knee  with  left. 
Raise  thigh  and  circumduct  it,  the  knee  describing  as  large  a  circle  as 
possible. 

Exercises  with  Resistance. — 1.  Reclining  position.  Flex  and  ex- 
tend thighs. 

2.  Semi-reclining  position,  with  knees  drawn  up.  Abduct  and 
adduct  thighs. 

The  prescription  for  treatment  may  be  arranged  in  this  order: 
active  exercises,  passive  exercises,  exercises  with  resistance,  ending 
with  some  deep-breathing  exercises. 

FLAT-FOOT 

Flat-foot  is  a  condition  in  which  the  Hgaments  and  muscles  of  the 
foot  are  abnormally  weak,  and  in  which  the  anteroposterior  arch  may 
be  partially  or  wholly  depressed  and  flattened. 

The  leg  is  rotated  inward  and  the  foot  everted;  the  weight  of  the 
body  falls  on  the  inner  side  of  the  foot;  the  interior  malleolus  is  prom- 
inent; the  entire  sole  of  the  foot  rests  on  the  floor;   and  when  the  feet 


FLAT-FOOT  845 

are  placed  side  by  side  and  the  toes  and  heels  touch,  the  natural  concavity 
of  the  inner  line  of  the  foot  is  replaced  by  a  convexity.  The  patient 
complains  of  pain  or  weakness,  and  the  tissues  of  the  sole  are  weak  and 
flabby. 

There  are  different  methods  of  examining  the  outlines  of  the  sole 
of  the  foot:  standing  with  the  foot  on  a  plate  of  glass  so  that  the  sole 
of  the  foot  may  be  seen  from  beneath;  smearing  the  sole  with  vaselin 
and  standing  on  a  piece  of  blotting-paper;  smearing  it  with  charcoal 
and  standing  on  a  piece  of  white  paper,  etc. 

The  patient  should  have  proper  rest.  He  should  frequently  sit 
with  feet  elevated  and  avoid  exhaustion.  When  standing,  he  should 
occasionally  invert  the  feet,  and,  when  walking,  walk  with  the  feet 
parallel,  as  the  Indians  do,  and  for  short  distances  walk  on  the  outer 
borders  of  the  feet. 

The  feet  should  be  cared  for  each  day,  giving  attention  to  the  nails 
and  to  bathing.  Apply  hot  and  cold  water  alternately,  and  rub  vigor- 
ously in  order  to  stimulate  the  muscles  and  the  circulation. 

The  feet  should  be  properly  clothed;  the  stockings  should  be  even, 
smooth,  and  loose,  but  should  not  heat  the  feet.  The  shoes  should  be 
broad  enough  to  permit  free  use  of  the  muscles  of  the  feet;  the  toe  of 
the  shoe  should  point  shghtly  inward,  and  the  inner  border  may  be 
raised;  the  heels  should  be  low  and  broad. 

The  general  condition  of  the  patient  should  be  carefully  considered, 
his  general  tonicity — for  its  impairment  will  affect  the  condition  of 
the  feet.  Judgment  should  be  used  in  the  care  and  use  of  the  feet  in 
rheumatism,  and  during  and  shortly  after  convalescence  where  there 
is  a  general  relaxation  of  muscles  and  ligaments.  Malnutrition  and 
obesity,  if  present,  should  receive  attention  while  the  feet  are  being 
treated. 

In  severe  cases,  in  the  beginning,  the  patient  should  be  kept  entirely 
off  his  feet,  and  given  only  passive  exercises,  massage,  and  bathing. 

Exercises. — 1.  Reclining  or  semi-reclining  position.  Extend  foot 
against  resistance. 

2.  Reclining  position.     Addiict  and  invert  foot  against  resistance. 

3.  Reclining  position.  Circumduct  foot  inward,  upward,  and  out- 
ward with  resistance  applied  to  the  inward  and  upward  motion. 

4.  Standing  position.     Rise  on  toes. 

5.  Standing  position.  Rise  on  toes;  turn  heels  outward;  lower 
heels  slowly  to  floor. 

Passive  Exercises. — 1.  With  one  hand  hold  heel  firm,  at  the  same 
time  pressing  on  the  astragalus  with  an  outward,  upward  motion  of 
the  thumb,  while  the  other  hand  adducts,  inverts,  and  flexes  the  foot. 
This  may  be  done  under  hot  water  if  the  deformity  is  marked. 

2.  Extension  of  foot. 

3.  Adduction  of  foot. 

Massage. — Deep  kneading,  vibration,  and  clapping  may  be  given 
to  the  foot  and  to  the  muscles  of  the  calf  of  the  leg. 

A  gauze  pad  may  be  placed  under  the  arch,  and  held  by  adhesive 


846  THE  PRACTICE  OF  PEDIATRICS 

plaster  or  a  rubber  bandage,  until  a  well-fitted  plate  can  be  made, 
which  should  be  used  for  support  in  the  intervals  between  treatments, 
until  the  muscles  and  ligaments  have  gained  sufficient  strength  to 
hold  the  arch  in  a  normal  position. 


XXIL  DRUGS  AND  DRUG  DOSAGE 

DRUGS  FOR  INTERNAL  USE 


Drug. 


ACETANILID. 

Not  advised  in  the  treatment  of  chil- 
dren. 
Acm,  Arsenious.     See  Arsenic. 
Acid,  Benzoic.     Benzoic   acid;   flowers   of 
benzoin. 

Used  in  cystitis  of  alkaUne  type , 

Acid,  Gallic. 

Bismuth  subgallate.     (Dermatol.) 

Used  internally  as  an  intestinal  astrin- 
gent, also  externally 

Acid,     Hydrochloric,     Dilute.     (Corre- 
sponding to  31.9  per  cent,  of  abso- 
lute HCl.) 
Used  in  chronic  gststritis  with  atony 

of  the  stomach 

Acid,  Lactic. 

Used  in  fermentative  diarrheas.     Given 
best  well  diluted  with  syrup  and  water 

and  at  two-hour  intervals 

Acid,   Phosphoric,   Dilute.     (Containing 
10  per  cent,  orthophosphoric  acid.) 

Used  as  a  stomachic 

Acid,  Salicylic. 

Seldom  used  uncombined. 
Bismuth  subsalicylate. 

Intestinal  astringent  and  sedative.  . .  . 
Methyl  salicylate.   (Synthetic  oil  of  winter- 
green.) 

Antirheumatic 

Oil  of  wintergreen.     (Natural.) 

Antirheumatic 

Salol.     (Phenyl  salicylate.) 

Intestinal     antiseptic     and     antirheu- 
matic   

Sodium  salicylate. 

Antirheumatic 

Aspirin.  (Non-oflficial.)  (Acetyl-salicylic 
acid.) 
Antirheumatic — a  substitute  for  so- 
dium saMcylate,  being  less  irritating  to 
the  stomach.  Best  given  in  capsules, 
for  it  is  decomposed  by  alkalis  and  by 

moisture 

Acid,  Tannic. 

Used  in  the  form  of: 
Tannalhin.     (Dried   albuminate   of   tan- 
nin.) 
Used  as  an  intestinal  astringent 

'  847 


Dose. 


6  Months.     18  Months.     3  Years.      5  Years, 


1  gr. 
3-5  gr. 


1-2  drops 

1  gr. 

1  drop 
1  drop 

2  gr. 
1  gr. 


1  gr. 


1-2  gr. 


1-2  gr. 
5  gr. 

1  drop 

1  drop 
2-3  drops 

1-2  gr. 

2-3  drops 
2-3  drops 

1-2  gr. 

1-2  gr. 

1-2  gr. 
1-2  gr. 


2gr. 
10  gr. 

2  drops 

2  drops 
5  drops 

2gr. 

3  drops 
3  drops 

2gr.' 
2-3  gr. 

2-3  gr. 
2-3  gr. 


3-5  gr. 
10  gr. 

3-5  drops 

3-5  drops 
10  drops 

3-5  gr. 

3-5  drops 
3-5  drops 

3gr. 
3-5  gr. 

3-5  gr. 
3-5  gr. 


848 


THE   PRACTICE    OF   PEDIATRICS 


Dbtjg. 


Dose. 


6  Months.     18  Months.     3  Years.       5  Years 


Acid,  Tannic  {Continued). 
Tannigen.     (Acetj^l-tannin.) 

Used  as  an  intestinal  astringent . 

Also  by  rectum:  1  per  cent,  solution  of 
tannic  acid  in  an  enema,  for  dysentery  or 
colitis. 
Acid,  Tartaric. 

Seldom  used  except  as  one  of  its  salts. 

Potassimn  bitartrate.     (Cream  of  tartar.) 

Diuretic,     refrigerant,     and     aperient. 

Used  as  an  ingredient  of  diuretic  drinks. 

To  one   pint  of    water  to  be   drunk   in 

twenty-four  hours  is  added : 

Potassium  and  antimony  tartrate.  (Tar- 
tar emetic.) 
Used  as  an  expectorant.  Its  action 
is  too  violent  for  use  as  an  emetic.  Best 
given  alone  or  with,  ipecac  in  a,  tablet  or 
in  a  mixture  with  a  simple  ehxir. 

May   cause   severe   gastro-enteritis   in 

too  large  doses 

Potassium    and    sodium    tartrate.     (Ro 
chelle  salt.) 

Laxative 

Aconite.      (Aconitum     napellus.)  _    (Root 
contains  0.5  per  cent,  aconitin.) 
Tincture  oj  aconite  root  (10  per  cent.). 

Used  in  a  beginning  fever  as  a  circu- 
latory sedative  and  an  analgesic _. . 

Alcohol.     (Ethyl  alcohol,  spirits  of  wine.) 
Best  given  as  whisky  or  brandy  for 
a  general  stimulant  toward  the  end  of 
an  illness  or  as  a  last  resort. 
Brandy.     (Spiritus  vini  galUci,   contain- 
ing 39-47  per  cent,  alcohol  by  weight.) 


1-2  gr. 


2^6  gr- 
15  gr. 

J  drop 
5-10  drops 


Whisky.     (Spiritus     frumenti,     contain- 
ing 44-50  per  cent,  alcohol  by  weight.)  5-10  drops 

Sherry 


ry  wine.     (Vinum  xerici,  containing 
alcohol,  15-20  per  cent.,  by  weight.) 

Aloes. 

Not  advised  in  the  treatment  of  chil- 
dren. 
Alum. 

Not  advised  in  the  treatment  of  chil- 
dren. 
Ammonium. 

Ammonium  hromid.     See  Bromin. 
Ammonium  chlorid.     (Sal  ammoniac.) 
Stimulating    expectorant;   best    given 

dissolved  in  half  an  ounce  of  water 

Ammonium  carbonate.     (Sal  volatile.) 

Stimulating    expectorant;     best    given 
dissolved  in  half  an  ounce  of  water ....... 

Solution  of  ammonium  acetate.  (Liquor 
ammonii  acetatis  or  spirits  of  Minder- 
erus.) 


1-2  gr. 


2  dr. 


2-3  gr. 


igr. 


gr. 


Tiogr- 


30  gr. 


J  drop 


10-20 
drops 

10-20 
drops 

30  drops 


jh  gr- 


1-2  dr. 


1  drop 


20-30 
drops 

20-30 
drops 

45  drops- 
1  dr. 


3-5  gr. 


4  dr. 


ik  gr. 
3-4  dr. 

1-2  drops 


30-40 
drops 

30-40 
drops 

1-2  dr. 


-tgr. 


Mgr. 


1  gr. 
1  gr. 


1-2  gr. 
1-2  gr. 


DEUGS  FOR   INTERNAL   USE 


849 


Drug. 


Dose, 


6  Months.  I  18  Months.     3  Yeara.       5  Years. 


given 


Ammonium  {Continued). 

Stimulating    expectorant;     best 
well  diluted  in  carbonic  water. 

Used  also  as  a  diuretic,  antipyretic,  and 

diaphoretic 

Aromatic    spirits    of    ammonia.     (Spiri- 
tus  ammonii  aromaticus.) 

Used  as  a  stimulating  expectorant, 
volatile  stimulant,  carminative,  and  anti- 
spasmodic. Best  given  well  diluted  with 
water 


Antimony. 

Antimony  and  potassiu7n  tartrate.     (Tar- 
tar emetic.)     See  under  Acid,   Tar- 
taric. 
Antipyrin. 

Analgesic  and  sedative  in  pertussis  and 
laryngitis. 

Best  given  alone  in  powder  form,  or 

with  sodium  bromid  in  solution 

Antitoxin.     See  Serum,   Antidiphtheric. 
Apomorphin. 

Not  advised  in  the  treatment  of  chil- 
dren. 
Arsenic. 

Arsenious  acid.     (Arsenic  trioxid  or  white 

arsenic.) 

Used  in  anemia,  malaria,  and  chorea. 

Administered    either   in   solution    (see 

Fowler's  solution)  or  in  tablets  with  other 

ingredients. 

In  large  doses  it  is  an  irritant  poison, 
causing  puffiness  of  the  eyes  and  gastro- 
enteritis, both  of  which  are  signs  of  an 
overdose. 

Cannot  be  given  with  astringents,  tinc- 
tures, or  decoctions  or  with  solutions  of 
iron. 

Antidotes  are  hydrated  iron  with  mag- 
nesia, egg-albumen,  and  emetics. 

Given  three  times  a  day 

Fowler^s    solution.     (Liquor    potassii    ar- 
senitis.) 
Uses,    action,    and    antidotes    are   the 
same  as  those  of  arsenious  acid. 

Best  given  in  water  into  which  it  is 
freshly  dropped 

ASAFETIDA. 

Emulsion    of    asafetida.     (Milk    of    as 
fetida.) 

Used  chiefly  as  an  ingredient  of  ene- 
mata,  especially  in  excessive  tympanites. 

To  8  ounces  of  diluent 

AspiDiuM.     (Male-fern.) 
Oleoresin  of  male-fern. 
Teniafuge. 

Best  given  in  emulsion  or  in  capsules .  .  . 
Aspirin.     See  under  Acid,  Salicylic. 


54 


3  drops 


^Idr. 


3-5  drops 


1  dr. 


5  drops 


2  dr. 


5-10 
drops 


igr. 


1-U  gr. 


2gr. 


3  gr. 


5  drop 


^ff  gr- 


1  drop 


Idr. 


Ti(5-gr. 


2  drops 


Idr. 


10-15  gr. 


r^ij  gr- 


2-5  drops 


Idr. 


20-30  gr. 


850 


THE   PRACTICE    OF   PEDIATRICS 


Drug. 


Dose. 


6  Months.     18  Months.     3  Years.       5  Years 


Atropin.     See  under  Belladonna. 
Basham's  Mixture.     See  under  Iron. 
Belladonna.     (From  the   leaves    of    the 
Atropa   belladonna,    containing   0.35 
per  cent,  of  alkaloid.) 
Atropin.     (Alkaloid  of  belladonna.) 
Respiratory  stimulant,   antihidrotic. 
Used  as  a  stimulant,  a  mydriatic,  and 

for  the  cure  of  enuresis 

Tincture    of    belladonna     (10    per     cent, 
leaves) . 

Uses  similar  to  those  of  atropin 

Belladonna     leaves.      (Asthma    powder.) 

Used  occasionally  with  the  leaves  of 

conium  and  stramonium,  and  potassium 

nitrate   (saltpeter)   to  reheve  attacks  of 

asthma.     To    be   bm-ned   in    a   metallic 

receptacle. 

Benzoic  Acid.     See  Acid,  Benzoic. 

BiCHLOKiD  OP  Mercury.     See  under  Mer 

cury. 
Bismuth. 

Bismuth  subcarbonate. 

Intestinal  astringent  and  sedative .... 
Bismuth  subgallate.     (Dermatol.) 
Intestinal  astringent  and  sedative. 

Used  also  externally 

Bismuth  subnitrate. 

Intestinal  astringent  and  sedative .... 
Bismuth  subsalicylate.      See  under  Acid, 
Salicylic. 
Blaud's  Pill.     See  under  Iron. 
Borax.     (Sodium  borate.)     See  under  So- 
dium. 
Brandy.     See  under  Alcohol. 
Bromin. 

Used  only  in  the  form  of  its  salts. 
Ammonium  bromid. 

Sedative.  Used  in  laryngismus,  per- 
tussis, asthmatic  bronchitis,  and  sleep- 
lessness. 

Best  given  well  diluted  with  water 

Potassium  bromid. 

Used  same  as  the  ammonium  salt,  but 

it  is  more  depressing 

Sodium  bromid. 

Used  same  as  the  above.  It  is  midway 
between  the  ammonium  and  the  potas- 
sium salts  in  its  depressant  action 

Strontium  bromid. 

Used  same  as  the  above 

Brown  Mixture.     See  under  Licorice. 
Caffein. 

Caffein     sodiosalicylas     (50     per     cent. 

caffein) 

Caffein  sodiobenzoas 

Citrate  of  caffein  (50  per  cent,  caffein). 
General  stimulant  and  diuretic 


^kgr- 


i-|  drop 


10  gr. 


3-5 
5-lb 


gr. 
gr. 


1-3 


1-3 


1-3 
1-3 


3*0  gr- 


1  drop 


^io  gr. 


1-2  drops 


10  gr. 

5gr. 
10  gr. 


gr. 


2-4  gr. 
2-4  gr. 

2-4  gr. 
2-4  gr. 


i-1  gr. 
1-1  gr. 

1-1  gr. 


^i-5  gr. 


3-5  drops 


10  gr. 

5-10  gr. 
10-15  gr. 


3-5  gr. 


3-5  gr. 
3-5  gr. 


1-U  gr. 
1-11  gr. 

1  gr. 


20  gr. 

10  gr. 
20  gr. 


5-8  gr. 


3-5  gr.      5-8  gr, 


5-8  gr. 
5-8  gr. 


U-2  gr. 
U-2  gr. 

1-2  gr. 


DRUGS   FOR   INTERNAL   USE 


851 


Dose. 


8  Months. 

3  Years. 

Igr. 
10  gr. 

1-2  gr. 
20  gr. 

■io  gr- 

^Vgr- 

3gr. 

5  gr. 

Idr. 

l^dr. 

igr- 

igr- 

5  drops 

5-10 
drops 

\-\  drop 

1  drop 

2-3 
drops 

10  di-ops 

15  drops 

^gr. 

1-2  gr. 

30-45 
drops 

Idr. 

2  dr. 

3  dr. 

2-3  gr. 

3gr. 

Calcium. 

Calcium  chlorid. 

Of  some  benefit  in  hemophilia  and  pm-- 

pura  hsemorrhagica 

Calcium  lactate 

Calcium  sulphid. 

Antipustulant 

Prepared  chalk. 

Antacid 

Compound  chalk  mixture.     (Mistm^a  cretse 
composita.) 

20  per  cent,  chalk  powder,  40  per  cent, 
cinnamon- water . 

Antacid.     Every  two  hours 

Calomel.     See  under  Mercury. 
Camphor. 

Powdered  camphor. 

Used  in  coryza.  Every  two  hoius 

Spirits  of  camphor  (10  per  cent,  in  alcohol) . 

Stimulant,  anodyne,  carminative 

Water   of  camphor.     (Aqua    camphorse.) 
(Contains  0.8  per  cent,  of  camphor.) 
Used  as  a  vehicle. 
Cantharides. 
Used  best  in: 
Tincture  of  cantharides  (10  per  cent.). 

Useful  in   cystitis   and  functional   al- 
buminuria   

Capsicum. 

Used  best  in: 
Tincture  of  capsicum  (10  per  cent.). 

Used  as  a  carminative  and  stomachic. 
Best  given  well  diluted  in  water 

Cardamom. 

Used  best  as: 
Tincture  of  cardamom. 

Used  as  a  carminative 

Cascara  Sagrada.     (Bark  of  Rhanmus  pur- 
shiana.) 
Extract  of  cascara  sagrada. 

(Four  times  the  strength  of  the  bark.) 

Tonic  laxative 

Cascara  Sagrada  {Continued). 

Fluidextract    of    cascara    sagrada.     (Aro- 
matic.)    (1  c.c.  =  l  gm.  bark.) 
The  active  principles  are  retained,  but 
the  bitter  principles  are  ehminated. 
Tonic  laxative 

Castor  Oil.     (Oleum  ricini.) 

(Expressed  from  the  seeds  of  Ricinus 
communis.) 

Bland  oil  and  cathartic. 

Given  usually  for  one  dose 

Cerium  Oxalate. 

Sedative  in  vomiting 

Chalk.     See  Calcium. 


i  gr- 
5  gr. 

Tff  gr- 
2gr. 


1  dr. 

TO  gr. 
3  drops 


5  drops 


15  drops 


Idr. 

2gr. 


2gr. 
20  gr. 

iVgr- 
5-8  gr. 


2  dr. 

igr. 
10  drops 


§  drop 


3-5  drops 


20  drops 


3-5  gr. 


1-2  dr. 


4  dr. 
3-5  gr. 


852 


THE   PRACTICE   OF   PEDIATRICS 


Drug. 


Chloral  Hydrate. 

Sedative,  hj^notic,  and  antispasmodic. 
Best  given  in  some  bland  fluid  by  rec- 
tum   

Chloroform.  , 

Given  internally  as: 
Spirits    of   chloroform.     (Chloric    ether.) 
(6  per  cent,  chloroform.) 
Carminative,  antispasmodic,  and  sed- 
ative  


Water     of     chloroform.     (Aqua     chloro' 
formi.)     (0.5  per  cent,  chloroform.) 

Vehicle  and  carminative 

Cinchona.     See  under  Quinin. 
CocAiN,  or: 

Cocain  Hydrochlorid. 

Local  anesthetic  by  hypodermic  in- 
jection. 

Used  in  0.2  per  cent,  to  4  per  cent, 
strength.  But  seldom  used  for  local  an- 
esthesia in  children.     Used  by  the  mouth 

in  obstinate  vomiting 

CoDEiN.     See  Opium. 
CoD-LiVER  Oil.     (Oleum  morrhuse.) 
Fixed  oil  from  fresh  cod's  hvers. 
Alterative  and  tonic. 
Given  three  times  a  day 


Dose. 


6  Months.     18  Months.     3  Years.       5  Years, 


2-3  drops 


dram 


Corrosive  Sublimate.    See  Corrosive  Chlo- 

rid  of  Mercury. 
Cream  of  Tartar.     See  under  Acid,  Tar- 
taric. 
Creosote.     (Beechwood  creosote.) 

Tonic,   alterative,   and  antitubercular 
Best  given  in  an  emulsion   with   cin- 
namon-water,   three   times   a   day   after 
meals .  .  .  .  • 


Creosotal.     (Carbonate    of    creosote — 92 
per  cent,  creosote.) 
Is  preferable  to  creosote  because  it  has 
Uttle  odor,  a  more  agreeable  taste,  and 
is  better  borne  by  the  stomach |  drop 


Dermatol.      (Bismuth     subgallate.)      See 

under  Bismuth. 
Digitalis.     (From  the  leaves  of  Digitalis 
purpurea.) 
Heart  stimulant  and  tonic;    also  diu- 
retic. 

Best  given  by  mouth  in  the  form  of  the 
tincture    and    hypodermically    either    as 
the  tincture  or  as  digitalin. 
Tincture  of  digitalis  (10  per  cent,  leaves) . 

Infusion    of    digitalis     (66  gm.  =  l    gm. 

leaves) 

Digitalin   (10  times  strength  of  leaves) 


1  gr. 


3-5  drops 


-2  dr. 


Ugr. 


5-15 
drops 

2-3  dr. 


10-15 
drops 


h  drop 


do  gr- 


15-20 
drops 


2  drops 


2  drops 


2  drop 


sh  gr- 


1  drop 


jh  gr. 


2gr. 


15-20 
drops 


4  dr. 


^V  gr-        ^5  gr- 


20-30 
drops 


1-1  dr. 


2-3 
drops 


2-3 
drops 


3-5  drops 


3-5  drops 


1-2 
drops 

1-1  dr. 


2-3  drops 

1-3  dr. 

rkgr- 


DRUGS  FOR   INTERNAL   USE 


853 


Drug. 


Dose. 


Months.    18  Months.     3  Years.       5  Years. 


Diphtheria  Antitoxin.     See  Serum,  An- 

tidiphtheric. 
Dover's  Powder.     See  under  Opium. 
Epsom  Salt.     See  under  Magnesium. 
Ergot.     (From  the  sclerotium  of  the  Clavi- 
ceps  purpurea  of  rye.) 
Hemostatic,     heart     and     circulatory 
stimulant. 
Fluidextract  of  ergot  {\  c.c.  =  l  gm.  ergot) 

Eriodictyon.     See  Yerba  Santa. 
Ether. 

Used  internally  as: 
Compound  spirits  of  ether.     (Hoffmann's 
anodyne,  32.5  per  cent,  ether.) 
Anodyne,  carminative,  antispasmodic, 
and  stimulant. 

Best  given  well  diluted  with  water 


Spirits  of  nitrous  ether.  (Sweet  spirit 
of  niter,  4  per  cent,  ethyl  nitrite.) 

Used  as  a  diaphoretic,  diuretic  and  car- 
minative. 

It  is  volatile  and  explosive  and  in- 
compatible with  many  drugs.  Best  given 
alone  or  in  a  simple  elixir 


See 


Fel  Bovis.     See  Ox-gall. 
Ferrtjm.     See  Iron. 
Fowler's  Solution.     See  Arsenic. 
Gallic  Acid.     See  Acid,  Gallic. 
Gentian. 
Extract  of  gentian. 

Stomachic  and  bitter  tonic. 

Given  tliree  times  a  day 

Glauber's  Salt.     (Sodium  sulphate.) 

under  Sodium. 
Glonoin.     See  Nitroglycerin. 
Glycerin. 

Used  chiefly  as  a  demulcent  base  and 
a  vehicle  for  other  drugs. 
Glycyrrhiza.     See  Licorice. 
Hexamethylenamin.     Official     name     for 

the  proprietary  urotropin,  q.  v. 
Hoffmann's  Anodyne.     See  under  Ether. 
Hydrargyrum.     See  Mercury. 
Hyoscyamus. 

Tincture  of  hyoscyamus. 
Sedative  and  antispasmodic. 

Ipecac  

Syrup  of  ipecac 

Iron.     Given  every  two  hours. 
Liquor  ferri  et  ammonii  acetatis. 

(Basham's    mixture — solution    of   iron 
and    ammonium    acetate — 10    per    cent. 

metallic  iron) 

Ovoferrin.     (Proprietary  organic  iron.) .  . . 

Pyrophosphate  of  iron   (10   per   cent,  of 
metallic  iron) 


2-3  drops 


5  drops 


5-8 
drops 


10-15 
drops 


2  drops 


3-5  drops 


5  drops 


2-3  drops  3-5  drops 


-1  drop 


5  drops 


5  drops 


-2gr. 


73  gr- 
1-2  drops 


10  drops 


^TTgr. 
3  drops 


^dr. 
15-20 
drops 


.5-10 
drops 


5-10 
drops 


-1  gr. 


Vffgr. 
3-5  drops 


1  dr.- 
20-30 
drops 


1-2  gr.      2-3  gr. 


854 


THE    PRACTICE    OF   PEDIATRICS 


Drug. 


Dose. 


Months.     18  Months.     3  Years.       5  Years. 


Iron  {Continued). 

Syrup  of  the  iodid  of  iron  (5  per  cent,  fer- 
rous iodid) 


Tincture  of  the  chlorid  of  iron. 

(35  per  cent,  of  ferric  chlorid  and  must 
be  at  least  one  year  old.) 


3  drops 


1  drop 


6  drops 


3  drops 


Jalap. 

Powdered  jalap.     (Contains  8  per  cent. 

resin.) 

Hydragogue  cathartic  and  diuretic 

Lactic  Acid.     See  Acid,  Lactic. 
Licorice. 

Compound  licorice  mixture.     (Brown  mix- 
ture— 12  per  cent,  paregoric.) 
Sedative  expectorant  mixture. 
Given  at  two-hour  intervals 


Compound  licorice  powder. 
Laxative 


Magnesium. 

Magnesium  carbonate. 
Antacid  and  laxative . 


Magnesium  citrate,  solution  of.  (Liquor 
magnesii  citratis.) 

Laxative.     For  one  dose 

Magnesium  oxid.     (Calcined  magnesia.) 

Antacid  and  laxative 


Magnesium  sulphate.     (Epsom  salt.) 

Laxative.  To  be  given  every  two  hours 
and  discontinued  when  the  desired  effect 
has  been  produced 


15  drops 


10  gr. 


5-10  gr. 


5-10  gr. 


10-15    gr. 


20  drops 


10-20    gr 


20  gr. 


10-20  gr. 


20  gr. 


Male-fern.     See  Aspidium. 
Mentbla.  Piperita.     See  Peppermint. 
Mentha  Viridis.     See  Spearmint. 
Mercury. 

Mass   of  mercury.     (Blue  mass — 35  per 
cent,  mercury.) 
Cathartic  and  antisyphilitic. 

Used  once  a  day .• . .  . 

Corrosive  chlorid  of  mercury.     (Bichlorid 
of  mercury  or  corrosive  subUmate.) 
Antisyphilitic. 

Given  three  times  a  day 

Mild     chlorid     of    mercury.     (Calomel.) 
Cathartic,    cholagogue,    antisyphihtic. 

At  thirty-minute  intervals 

At  one-hour  intervals 

Rarely  necessary  to  give  more  than  one 
grain  for  laxative  effect. 
Red  iodid  of  mercury.     (Biniodid.) 
Antisyphilitic. 
Given  three  times  a  day , 


gr- 


Tt(Tgr- 


:ho  gr- 


10  drops 
5  drops 

2gr. 


30-40 
drops 

30  gr. 


20-30 
drops 

10-15 
drops 


3gr. 


40  drops 
-Idr. 

40  gr. — 
Idr. 


30-40      40  gr.- 
gr.  1  dr. 


2  oz. 

20-30 
gr. 


20-30 
gr. 


1  gr. 


T*o  gr- 


gr- 


Tff  gr- 


2-4  oz. 

30-40 
gr. 


-Idr. 


1-2  gr. 


T%gr. 


gr. 


^VAgr. 


DRUGS   FOR   INTERNAL   USE 


855 


Dose. 

Drug. 

6  Months. 

18  Months. 

3  Years. 

5  Years. 

Mercury  (Continued). 

Mercury  with  chalk.    (Gray  powder.)    (38 

per  cent,  mercury.) 

Intestinal  antiseptic,  cholagogue,  and 

antisyphilitic. 

At  one-hour  intervals — total  1  gr 

Jgr. 

igr. 

At  one-hour  intervals — total  2  gr 

2gr. 

I'gr. 

Methyl  Salicylate.     See  under  Acid,  Sal- 

icylic. 

MiNDERERUs,  SPIRITS  OF.     See  under  Am- 

monium. 

MoRPHiN.     See  under  Opium. 

Myrrh. 

Tincture  of  myrrh  (20  per  cent.). 

Used   as   a  mouth-wash  diluted  with 

water. 

Niter.     See  under  Ether,  Sweet  Spirits  of 

Niter. 

Nitroglycerin.     (Glonoin,     glyceryl     tri- 

nitrate.) 

Vasodilator 

5^-g-  gr. 

■370^  gr. 

^W  g^' 

To^ir  gr. 

Spirits  of  glyceryl  trinitrate,  or  spirits  of 

glonoin,  old  U.  S.  P.  (1  per  cent,  al- 

cohohc  solution) 

i  drop 

i  drop 

§  drop 

1  drop 

Nxra:  Vomica.     (From  Strychnos  nux-vom- 

ica.) 

Tincture  of  nux  vomica  (1  per  cent,  strych- 

ninj. 
Stomachic  and  stimulant 

5  drop 

1  drop 

1-2  drops 

2-4  drops 

Strychnin.     (Alkaloid  of  nux  vomica.) 

General  stimulant,  well  borne  by  chil- 

dren. 

Every  two  or  three  hours 

1  . .  1 

TX7T  gr. 

rrtn  gr. 

ToTJ  gr. 

Oleum  Gaultherium.     (Oil      of      winter- 

4  0  0      2  0  0 

gr. 

1  0  u   & 

1  U  U    0* 

green.)     See  under  Acid,   Salicylic. 

Oleum  Morrhu^e.     See  Cod-liver  Oil. 

Oleum  Oliv^.     See  Olive  Oil. 

Oleum  Ricini.     See  Castor  Oil. 

Olive  Oil. 

Laxative  and  nutrient 

15  di'ops 

15-30 

30 

Idr. 

drops 

di'ops- 
Idr. 

Used  at  night  by  rectum  for  the  cm-e 

of  constipation 

1  oz. 

I2  oz. 

2  oz. 

3oz. 

Opium. 

Sedative,  anodyne,  hypnotic. 

Tincture  of  deodorized  opium  (10  per  cent.) 

Used  in  3-  to  10-drop  doses  in  enemata 

as  a  sedative  for  children  under  five  years 

of  age. 

Camphorated    tincture    of    opium.     (Par- 

egoric— 0.4  per  cent,  opium.) 

Sedative  and  analgesic 

3-5  drops 

10  drops 

15-20 

20-30 

drops 

di-ops 

Poivder  of  ipecac  and  opium.     (Dover's 

powder — 10  per  cent,  each  of  ipecac 

and  opium.) 

Sedative 

i-igr- 

^Igr. 

1-U  gr. 

2-3  gr. 

856 


THE   PRACTICE    OF   PEDIATRICS 


Drug. 


Dose. 


6  Months.     18  Months.     3  Years.       5  Years. 


Opium  (Continued). 

Morphin.     (Alkaloid  of  opium.) 

Not  weU  borne  by  children  and  best 

given  hypodermatically 

Codein.     (Methylmorphin.) 

As  sulphate  or  phosphate 

Heroin.     (Diacetyltoorphin.) 
As  hydrochlorid. 

Bronchial  sedative 

Orange-juice.     (Citrus  aurantium.) 

Antiscorbutic 

Ox-gall.     (Fel  bovis — fresh  ox-bile.) 

Used  as  a  laxative  in  enemata — 3^-1 
dr.  to  a  pint  of  water. 
Paregoric.     Camphorated  tincture  of  opium 

See  under  Opium. 
Pepo.     See  Pumpkin  Seed. 
Peppermint. 
Aqua  mentha  piperitce — Peppermint  water. 
(0.2   per   cent,   oil    of   peppermint.) 
Carminative,  sedative,  corrective,  and 

vehicle 

Pepsin. 

Powdered  pepsin 

Essence  of  pepsin 


Phenacetin.     (Acetphenetidin.) 

Antipyretic  and  analgesic 

Phosphoric  Acid.     See  Acid,  Phosphoric 
Phosphorus. 

Oleum  phosphoratum  (1  per  cent,  in  alm- 
ond oil). 
Alterative 


Syrup  of  hypophosphites. 

(Calcium,  4.5  per  cent.;  sodium  and  po- 
tassium, each,  1.5  per  cent.) 

Pilocarpin. 

Not  advised  in  the  treatment  of  chil- 
dren. 
Potassium. 

Potassium  acetate. 

Diuretic,  refrigerant,  and  alterative.  .  .  . 
Potassium  bicarbonate. 

Should  not  be  given  to  children  on  ac- 
count of  its  disagreeable  taste. 
Potassium  bitartrate.     (Cream  of  tartar.) 

See  under  Acid,  Tartaric. 
Potassium  bromid.     See  under  Bromin. 
Potassium  citrate. 

Diaphoretic  and  diuretic. 

Used  in  acute  bronchitis 

Potassium  chlorate. 

Astringent  and  antisialogogue. 

Used  in  stomatitis  of  every  type,  in 

tonsillitis  and  angina 

Potassium  iodid. 

Antispasmodic  and  antisyphilitic 


ruogr- 


Idr. 

1  gr. 
20  drops 


drop 


^dr. 


1-2  gr. 


1-1  gr- 

i  gr- 
1  gr. 


Tto  gr. 
sVgr- 

jh  gr- 


1-2  dr. 

1-2  gr. 
30-40 
drops 


1  gr. 


1  drop 


dr. 


2-3  gr. 


1-2  gr. 

1  gr. 
1-2  gr. 


To  gr. 
To  gr. 

-STS  gr. 


3  dr. 

2-3  gr. 

40 

drops- 

1  dr. 

Hgr. 


drops 


Idr. 


3gr. 


3gr. 

2-3  gr. 
2-3  gr. 


26  gr- 
I  gr. 

3V  gr. 
1  oz. 


4  dr. 

3  gr, 
1  dr. 


2gr. 


2-4  drops 


1-2  dr. 


5  gr. 


4gr. 

3gr. 
3gr. 


DRUGS   FOR  INTERNAL  USE 


857 


Drug. 


Dose. 


6  Months.     18  Months.     3  Years, 


5  Years. 


Potassium  {Continued). 

Potassium    and    sodium    tartrate.     (Ro- 
chelle  salt.)     See  under  Acid,   Tar- 
taric. 
Pruntjs  Virginiana.     See  Wild  Cherry. 
Pumpkin  Seed.     Pepo. 

Teniafuge.     Best    given   in    an    emul- 
sion; average  dose,  1  dr. 
Quassia. 

Infusion  of  quassia. 
Vermifuge. 

An  extemporaneous  infusion  is  made 
by  adding  1  or  2  ounces  of  quassia  chips 
to  a  pint  of  water.  This  is  injected  high 
up  into  the  bowel. 

Used  particularly  to  destroy  the  Oxy- 
uris  vermicularis. 
QuiNiN.     (Alkaloid  of  cinchona.) 

Bisulphate  of  quinin 

Sulphate  of  quinin 

Tincture  of  cinchona 


All  these  are  bitter  tonics  and  anti- 

periodics. 

Rhamnus  Purshiana.     See     Cascara     Sa- 

grada. 
Rhubarb. 

Powdered  rhubarb. 

Laxative 

Rhubarb  (Continued). 
Aromatic  syrup  of  rhubarb. 

Laxative  and  flavoring  medium 

Mixture  of  rhubarb  and  soda.  ■ 

Corrective  and  laxative. 
I^.     Pulveris  rhei, 

Sodii  bicarbonatis aa  xlviij 

Syrupi  rhei  aromatici 5  J 

'     Aquae q.  s.  ad  §ij 

M.     Sig. — One  to  three  doses  daily 

RocHELLE  Salt.     See  under  Acid,  Tartaric 
Saccharin.     (Benzosulphinidum.) 

Substitute  for   sugar,    but   200   times 
sweeter. 

For  8  oimces  of  food,  3^-1  grain  is  suffi- 
cient. 
Saccharose.     See  Sugar. 
Salicylic  Acid.     See  Acid,  Salicylic. 
Salol.     See  under  Acid,  Salicylic. 
Santonin.     (Anhydrid  of  santoninic  acid.) 
Vermifuge,    for    round-worms    partic- 
ularly  

Senna. 

Cathartic.     Best   given   as   compound 
licorice  powder,  of  which  it  is  an  ingre- 
dient (q.  v.). 
Serum  Antidiphtheriticum.     (Diphtheria 
antitoxin.) 
For  immunization: 
2000  to  5000  units. 


1  gr. 
Igr. 


1-2  gr. 
Idr. 

idr. 


1-2  gr. 

1-2  gr. 

5-10 

drops 


2-3  gr. 
2  dr. 

2  dr. 


2-3  gr. 
2-3  gr. 

15 
drops 


3-4  gr. 
3  dr. 

3  dr. 


3-4  gr. 

3-4  gr. 
20-30 
drops 


5gr. 
4  dr. 

4  dr. 


i  gr. 


1  gr. 


1-2  gr. 


2gr. 


858 


THE    PRACTICE    OF   PEDIATRICS 


Drug. 


Dose. 


6  Months.     18  Months.     3  Years.       5  Years. 


Sebum  Antidiphtheriticum  {Continued) 
In  faucial  diphtheria: 

5000  to  10,000  units  and  repeat  in  eight 
hours  if  required. 
In  laryngeal  diphtheria: 

10,000  units  and  repeat  in  eight  hours  if 
required. 

The  repetition  of  the  doses  of  antitoxin 
is  discontinued  only  when  the  case  ceases 
to  require  the  serum. 

The  dosage  is  independent  of  the  age 
of  the  patient. 
Sodium. 

Sodium  benzoate. 

Antiseptic,  antipyretic,  and  antirheu- 
matic. 

Used  in  cystitis  with  alkaline  fermen 
tation  to  acidify  the  urine,  which  it  does 

by  the  liberation  of  hippuric  acid 

Sodium  bicarbonate. 

Antacid,  antirheimaatic 

Sodium  borate.     (Borax.) 

Antiseptic  and  astringent. 

Used  as  a  gargle  and  mouth-wash  in 
angina  and  stomatitis — 1  dr.  to  8  oz.  of 
water. 

Sodium  bromid.     See  under  Bromin. 
Sodium  iodid. 

Uses    and  doses  the  same  as  those  of 
potassium  iodid  {q.  v.). 
Sodium  phosphate. 

Laxative  and  cholagogue 

Sodium  sulphate.     (Glauber's  salt.) 

Cathartic. 

Used  in  intestinal  infection  of  inactive 
type 


Sodium  salicylate.     See  under  Acid,  Soli 
cylic. 
Spearmint.     (Mentha  viridis.) 

Water  of  spearmint.     (Aqua  menthse  viri- 
dis— 0.2  per  cent,  oil  of  spearmint " 
Carminative,  sedative,  corrective,  and 

vehicle 

Strontixtm. 

Strontium  bromid.     See  under  Bromin. 
Stbophanthus. 

Tincture  of  strophanthus  (11  per  cent,  in 
New  Pharmacopeia,  or  twice  former 
strength) . 

Cardiac  tonic  and  diuretic.  Preferred 
to  digitalis  in  the  treatment  of  children 

because  better  borne 

Strychnin.     See  imder  Nux  Vomica. 
Sugar.     (Cane-sugar    or    saccharose.) 

Sweetening  agent.  May  be  substi- 
tuted for  lactose  in  the  adaptation  of  cow's 
milk  for  infant-feeding. 

1  level  tablespoonful  equals  J^  oz. 


1  gr. 
1-2  gr. 


1-2  gr. 
2gr. 


2gr. 
3gr. 


3gr. 
5gr. 


5-10  gr. 


15-30  gr. 


10-15    gr 


30-45    gr 


Idr. 


1  drop 


2  dr. 


1-2  drops 


15-20gr 


40  gr.- 
Idr. 


3  dr. 


2  drops 


20-30  gr. 


1  dr. 


4  dr. 


2-3  drops 


DRUGS   FOR   EXTERNAL   USE 


859 


Dose. 

Druo. 

6  Months. 

18  Months. 

3  Years. 

5  Years. 

Sugar  of  Milk.     (Lactose.) 

Used  as  an  excipient  and  in  the  adapta- 

tion of  cow's  milk  for  infant-feeding. 

1  level  tablespoonful  equals  H  oz. 

SULPHONAL. 

Not  advised  in  the  treatment  of  chil- 

dren. 

Sulphur. 

Precipitated  sulphur,  or  milk  of  sulphur. 

Laxative  and  alterative.     Given  usu- 

ally in  syrups  or  other  heavy  vehicles .... 

5gr. 

5-10  gr. 

15-30 

Idr. 

Used  also  as  a  reducing  agent  in  bis- 

gr. 

muth  mixtures  when  the  stools  do  not 

become  dark  colored 

1  gr. 

1  gr. 

1  gr. 

Igr. 

Tannalbin.     See  under  Acid,  Tannic. 

Tannigen.     See  under  Acid,  Tannic. 

Tartar  Emetic.     See    under    Acid,     Tar- 

taric. 

Tartaric  Acid.     See  Acid,  Tartaric. 

Terebene. 

Stimulating  expectorant  and  antisep- 

tic  

1  drop 

1-2 

2  drops 

drops 

Terpin  Hydrate. 

Expectorant  and  antiseptic. 

Used  in  subacute  and   chronic  bron- 

chitis   

Igr. 

igr. 

Trional. 

Not  advised  in  the  treatment  of  chil- 

dren. 

Urotropin.     (Trade  name  for  hexamethy- 

lenamin.) 

Urinary  antiseptic  and  sedative 

igr. 

Igr. 

1-2  gr. 

2-5  gr. 

Whisky.     See  under  Alcohol. 

Wild  Cherry. 

Syrup  of  ivild  cherry.     (Syrupus  pruni  vir- 

giniani.) 

Bronchial  sedative  and  vehicle. 

Contains  hydrocyanic  /acid 

|dr. 

1  dr. 

DRUGS  FOR  EXTERNAL  USE 

Acid,  Boric. 

Antiseptic  of  mild  grade.     4  %  is  a  saturated  solution. 

Used  both  in  solution  and  in  ointments. 

In  the  form  of  scales  it  is  most  soluble  and  most  convenient. 
Acid,  Carbolic.     See  Phenol. 
Acid,  Chromic.     (Chromic  Trioxid.) 

A  very  strong  caustic  and  astringent,  used  as  a  substitute  for  Nitrate  of  Silver. 
Acid,  Nitric  (68  %  pure  acid). 

Used  as  a  caustic. 
Acid,  Salicylic. 

Used  in  lotions  or  in  ointments,  1  %  to  3%,  for  skin  affections. 
Acid,  Tannic. 

Astringent. 

Used  in  1  %  solution  in  dysentery ;  as  an  ingredient  of  suppositories  for  hem- 
orrhoids.    See  also  Glycerite  of  Tannin  under  Glycerin. 


860  THE   PRACTICE    OF   PEDIATRICS 

Adrenalin.     (Trade  name  for  the  active  principle  of  the  Adrenal  Gland.) 

Used  in  a  solution  in  the  strength  of  1  part  to  1000  of  normal  saUne  solution 
or  sterihzed  oil. 

Local  hemostatic  and  astringent.     It  will  render  bloodless  the  field  of  opera- 
tion of  the  eye,  nose,  and  throat,  but  its  use  is  often  followed  by  hemorrhage. 
Aluminium  Acetate,  Solution  of. 

Antiseptic  dressing  for  celluhtis,  abscesses,  etc. 

1.  I^      Aluminii  sulphatis 333^ 

Acidi  aeetici 3  4  J^ 

Aqu£B 5 10 

2.  I^      Calcii  carbonatis Bl/^ 

Aqua; 52J^ 

Add  1  to  2,  stirring. 

Amtlum.     See  Starch. 
Argentum.     See  Silver. 
Akgyrol.     See  Silver. 
Aristol.     (Thymol  Di-iodid.) 

Mild  antiseptic,  used  as  a  dusting-powder  or  in  ointments. 
Balsam  of  Peru. 

A  stimulating  dressing  for  wounds  and  ulcers. 

In  Castor  Oil,  one  part  of  the  Balsam  to  six  of  the  oil.     It  makes  a  useful  ap- 
plication for  burns  and  wounds. 
Benzoin. 

Compound  Tincture  of  Benzoin. 

Used  as  a  bronchial  sedative  in  steam  inhalations,  one-half  ounce  to  two  pints 
of  water. 
BicHLORiD  OF  Mercury.  See  under  Mercury. 
Bismuth  Subgallate.     (Dermatol.) 

Used  externally  as  a  drying  antiseptic  powder,  either  pure  or  in  combination. 
Also  as  an  ingredient  of  ointments  of  10%  to  20%  strength. 
BoRAcic  Acid.     See  Acid,  Boric. 
Cacao-butter.     (Oleum  Theobromatis.) 

A  fixed  oil  expressed  from  the  seeds  of  the  Theobroma  Cacao.     Melts  at  30°- 
35°C.  (86°-95°F.). 

Used  as  an  emollient  and  as  a  base  for  suppositories.     It  may  be  used  for  nu- 
trient inunctions,  but  it  is  less  effective  than  Goose  Oil. 
Calamine.     (Zinc  Carbonate.) 

Used  as  an  ingredient  of  soothing  lotions  in  itching  affections  of  the  skin — ec- 
zema, urticaria,  dermatitis  venenata,  etc. 
Calomel.     See  under  Mercury. 
Cantharides. 

Vesicant.     Used  best  in  the  form  of  Collodion  of  Cantharides,  q.  v. 
Carron  Oil.     (Linimentum  Calcis.) 

Consists  of  equal  parts  of  Lime-water  and  Linseed  Oil. 
Used  as  a  soothing  apphcation  for  burns  and  scalds. 
Chloroform. 

Locally  a  rubefacient  and,  when  confined,  a  vesicant  as  well.     A  useful  in- 
gredient of  liniments. 

By  inhalation,  a  general  anesthetic. 
Chrtsarobin. 

Used  in  5%  ointment  for  psoriasis  and  tinea  tonsurans. 
Cocain. 

Alkaloid  obtained  from  several  varieties  of  Coca. 

A  local  anesthetic  when  applied  to  wounds  or  mucous  surfaces  or  when  in- 
jected hypodermically. 

For  local  application,  3%  to  10%  solutions. 
For  hypodermic  use,  0.2%  to  4%  solutions. 
CoD-LivER  Oil. 

May  be  used  locally  as  a  nutrient  inunction,  but  its  odor  is  objectionable. 
Collodion. 

Solution  of  Pyroxylin  in  Alcohol  and  Ether. 
Collodion  of  Cantharides  (60%  Cantharides).     An  excellent  bUstering  agent. 
Collodion  of  Ichthyol  (10%-20%).     Used  to  cover  the  wound  after  aspirations 
or  lumbar  punctures,  and  in  checking  the  spread  of  erysipelas. 


DEUGS   FOR   EXTERNAL   USE  861 

Collodion  of  Iodoform  (5%).     Used  in  erysipelas. 

Collodion  of  Oil  of  Cade  (l%-5%).     Used  in  eczema. 

Collodion  of  Salicylic  Acid  (10%).     Used  in  removing  corns  and  calluses. 
Creosote. 

Used  in  inhalations  as  a  pulmonary  antiseptic. 
Dermatol.     See  Bismuth  Subgallate. 

EUCAIN. 

.  Beta-eucain.  Local  anesthetic  with  action  and  uses  similar  to  those  of  Co- 
cain,  but  without  its  toxicity.  Solutions  can  be  steriUzed  without  injury  by 
boihng. 

FORMALDEHYD. 

Antiseptic  and  deodorant. 

Used  in  solutions  of  from  0.5%  to  2%  strength,  as  an  antiseptic. 
Used  in  the  form  of  the  gas  for  disinfecting,  the  gas  being  generated  by  heat, 
from  solutions,  or  from  the  soUd,  Paraform. 
Glycerin. 

Used  chiefly  as  a  solvent  or  excipient.     Very  hygroscopic.     It  is  the  base  of 

the  Glycerites. 

Glycerite  of  Carbolic  Acid — 20%  phenol  in  glycerin.     An  external  antiseptic  and 

antipruritic. 
Glycerite  of  Starch — 10%.     A  vehicle  for  skin  preparations  and  for  pills. 
Goose  Oil. 

The  oil  tried  from  the  goose.     An  excellent  oil  for  nutrient  inunctions.     It  is 
better  than  Olive  Oil  or  Cacao-butter,  for,  being  an  animal  oil,  it  is  more  readily 
absorbed  by  the  skin.     It  is  semifluid,  has  a  low  melting-point,  and  does  not  be- 
come hard  after  having  been  rubbed  in. 
Grindelia  Robusta. 

The  fluidextract,  in  the  strength  of  one  dram  to  a  pint  of  water,  is  used  aa  a 
wet  dressing  in  dermatitis  venenata. 

GUALACOL. 

Combined  with  equal  parts  of  Glycerin,  it  is  used  in  acute  joint  affections,  for 

its  analgesic  effect. 
Hamamelis.     See  Witch-hazel. 
Hydrargyrum.     See  Mercury. 
Hydrogen  Peroxid. 

Antiseptic  and  deodorizer.     Used  in  10-volume,  3%  solution  to  clean  wounds, 
and  to  dissolve  and  destroy  pus. 
Ichthyol. 

Used  in  1%  solution  in  intertrigo. 

Used  in  5%  to  50%  solutions  in  skin  diseases  or  in  erysipelas. 

Used  in  5%  to  50%  ointments  in  skin  diseases  or  in  erysipelas. 

Used  suspended  in  oil  in  strength  of  5%  to  25%  as  a  nasal  spray. 

lODIN. 

Tincture  of  lodin  (7  %) . 
Antiseptic  and  counterirritant. 

Used  particularly  in  tinea  tonsurans  and  tinea  circinata. 
Iodoform.     Formyl  Tri-iodid. 
Antiseptic  and  alterative. 

Used  in  the  form  of  a  powder,  an  ointment,  or  on  gauze  in  the  strength  of  5% 
to  10%. 
Kaolin. 

Cataplasma  Kaolini. 

A  smooth,  homogeneous  mass,  consisting  of  Kaolin,  Boric  Acid,  Thymol, 
Methyl  Salicylate,  Oil  of  Peppermint,  and  Glycerin. 
Lanolin. 

Used  as  an  ointment  base. 
Lead  and  Opium  Wash. 
Anodyne  lotion. 

I^.     Liquoris  plumbi  subacetatis 5iv 

Tincturae  opii 5  j 

Aquse 5  xvj 

Fiat  mistura. 

Sig. — LTse  externally. 


862  THE    PRACTICE    OF   PEDIATRICS 

Menthol.     (Peppermint  Camphor.) 

Sedative,  analgesic,  refrigerant,  and  antipriu-itic. 

Used  in  ointments,  1%  to  5%. 

Used  in  oily  solutions,  1%  to  5%. 

Used  triturated  with  equal  parts  of  Camphor  as  an  anodyne. 
Mercuby. 

Bichlorid  of  mercury. 

Antiseptic.     Used  in  1  :  1000  to  1  :  20,000  solutions. 
Calomel. 

A  milder  antiseptic  than  the  foregoing.     Used  as  a  dusting-powder  in  eye  af- 
fections and  in  the  lesions  of  secondary  syphilis. 
Mercury  and  ammonium  chlorid.     (White  precipitate.) 

Used  in  ointments  of  1%  to  10%  strength  as  an  antiparasitic  and  antisyphil- 
itic.     Of  particular  value  in  impetigo  contagiosa,  ringworm,  etc. 
Yellow  oxid  of  mercury. 

Antiseptic.     Used  in  ointments  of  0.5%  to  10%  strength  in  ophthalmia. 
Of  value  also  in  ringworm  and  syphihtic  eruptions. 

MUSTAED. 

Counterirritant. 

In  the  form  of  papers  (chartce)  for  local  pain  or  vomiting. 

In  the  form  of  powder: 

In  pastes  of  a  strength  of  1  part  of  mustard  to  from  2  to  6  parts  of  flour. 
In  baths — 1  tablespoonful  to  6  gallons  of  water. 
In  packs,  in  the  same  proportion. 
Oil  op  Cade.     (Oil  of  Juniper  Tar.) 

Used  as  an  antiparasitic  in  skin  diseases. 
In  powders,  1%  to  5%  in  a  base  of  stearate  of  zinc. 
In  ointments,  1%  to  5%. 
In  collodion,  1%  to  5%. 
Oil  of  Turpentine.     (Spirits  of  turpentine.) 
Rubefacient  and  counterirritant. 
Used  as  an  ingredient  of  liniments. 

Used  in  the  form  of  turpentine  stupes  for  the  relief  of  abdominal  distention. 
Flannel  cloths  are  wrung  out  in  hot  wafcer  to  each  pint  of  which  10-20  drops  of  oil 
of  turpentine  have  been  added,  and  are  then  applied  to  the  abdomen. 
Olive  Oil. 

Used  externally  as  a  nutrient  inunction. 
Petrolatum  (Petroleum  Jelly  or  "VaseUn")- 

Used  as  a  base  for  ointments. 
Phenol.     (Pharmacopeial  name  of  Carbolic  Acid.) 
Local  anesthetic  and  antiseptic. 

Used  as  an  antiseptic  in  solutions  of  the  strength  of  5%  or  less. 
Used  as  a  caustic  and  local  anesthetic  in  strength  of  95%. 
Children  are  very  susceptible  to  phenol  poisoning. 
Pes  Liquid  a.     See  Tar. 
Potassium  Permanganate. 

Antiseptic  and  disinfectant. 

Used  in  solutions  in  the  strength  of  1  :  4000  to  1  :  2000  on  mucous  surfaces, 
and  in  the  strength  of  1  :  1000  on  ulcers  and  superficial  wounds. 
Resorcin. 

Antiseptic  in  skin  diseases,  particularly  in  seborrheic  eczema. 
Lotions,  1%  to  5%. 
Ointments,  1%  to  5%. 
Silver. 

Silver  Nitrate.     Antiseptic  and  astringent.     Used  in  solutions  of  1%  to  50% 
strength.     As  a  caustic,  it  is  used  in  the  solid  form. 
Argyrol.     (Silver  Vitellin — Proprietary.) 

A  mild  antiseptic,  not  approaching  the  nitrate  in  efficacy.     Used  in  solutions 
of  5%  to  50%  strength  or  in  ointments  of  5%  to  50%  strength. 
Sodium  Bicarbonate. 

Used  in  saturated  solution  as  an  antipruritic  and  as  an  analgesic  in  skin  dis- 
eases and  burns. 
Starch. 

Used  as  the  base  of  drying-powders. 
Sulphur. 

In  5%  to  25%  ointments  as  a  parasiticide,  particularly  in  scabies. 


DRUGS   FOR   EXTERNAL  USE  863 

Tak.     (Pix  Liquida.) 

Antiseptic.     Used  in  skin  diseases  as  the  official  ointment  (50%)  or  in  oint- 
ments with  other  ingredients. 
Zinc  Oxid. 

Used  as  a  20%  ointment  in  benzoinated  lard,  in  skin  diseases,  such  as  eczema, 
needing  a  mild  astringent. 

Used  in  dusting-powders  in  the  strength  of  5%  to  10%. 

Official  zinc  ointment  makes  a  good  base  for  stronger  antiseptics,  such  as  tar 
and  oil  of  cade. 


INDEX 


Abbe  on  removal  of  kidney  sarcoma,  439 
Abdomen,  tuberculosis  of,  364 
Abdominal  breathing,  813 

tonsil,  252 

tuberculosis,  694 
treatment,  695 
Abscess,    acute   retropharyngeal,    275- 
277 

ischiorectal,  262 

mammary,  in  new-born,  155 

of  liver,  264 

peritonsillar,  283 

pulmonary,  360 
Absence,  congenital,  of  bile-ducts,  153 

of  esophagus,  171 
Abt  on  diabetes  melUtus,  735 
Acarus  scabiei,  572 
Accoucheur  hand  in  tetany,  494 
Acetonuria,  737 

treatment,  738 
Achondroplasia,  725-727 
Acidosis,  713 

cyclic  vomiting  with,  714,  715 

etiology,  713 

in  gastro-enteric  intoxication,  195 

in  lobar  pneumonia,  325 

pathology,  713 

symptoms,  714 

treatment,  715 
Aconite  in  acute  diffuse  nephritis,  447 
Adami  and   Nicholls  on  pathology  of 
typhoid,  658 
on  rachitis,  118 
Adams  position  in  scoliosis,  822 
Adenitis,  acute  cervical,  415 

simple,  glandular  fever  and,  differ- 
entiation, 419 

axillary,  417 

effect    of    removal    of    tonsils    and 
adenoids  on,  301 

in  influenza,  675 

in  scarlet  fever,  648 
treatment,  654 

inguinal,  417 

persistent  simple,  418 

retropharyngeal,  275 

spasm  and,  differentiation,  280 


Adenitis,  suppurative,  treatment,  417 

tuberculous,  420 
Adenocarcinoma  of  kidney,  439 
Adenoid  curets,  299 
face,  295 

tissue  in  leukemia,  408 
Adenoids,  293 

absence  of  facial  deformity  in,  295 
age  incidence,  294 

and  tonsils,   radical  removal,   adhe- 
sions after,  300 
benefits  from,  300 
as  cause  of  chronic  rhinitis,  269,  270 

of  cough,  272 
association  with  enlarged  tonsils,  296 
diagnosis,  296 
drop  jaw  in,  295 
etiology,  293 
facial  expression,  295 
method  of  examination  in,  296 
mouth-breathing  in,  294 
necessity  for   operative   interference 

in,  297 
operation  for  permanent  relief,  297 

for  temporary  relief,  296 
pathology,  293 
radical  removal  of,  298 
removal  of,  299 
rhinitis  in,  294 
symptoms,  294 
treatment,  296 
without  facial  deformity,  295 
Adenoma  of  brain,  502 

of  kidney,  438 
Adcnosarcoma  of  kidney,  439 
Adherent  pericardium,  393 

pleura  as  cause  of  cough,  273 
Agglutinins,  797 
Agoraphobia,  498 
Air,  cold,  in  acute  illness,  134 
in  lobar  pneumonia,  328 
for  nursing  mother,  25 
fresh,  for  dehcate  children,  126 
for  new-born  infant,  19 
for  premature  infant,  141 
in  habitual  loss  of  appetite,  80 
in  whooping  cough,  619 


55 


865 


866 


INDEX 


Airing  of  nursery,  37 
Albuminuria  in  scarlet  fever,  648 

orthostatic,  452 
Alcohol,  782,  783 

in  bronchopneumonia,  340 
in  lobar  pneumonia,  331 
in  sepsis  in  new-born,  147 
Alessandrini  on  pellagra,  738 
Alkalis  in  milk  adaptation,  63 
AllergA',  food,  79 
Alpine  scurvy,  738 
Amaurotic  family  idiocj^,  507-509 
Amberg     on     eosinophilia    in     amebic 

dysentery,  399 
Ammonia,  excessive  excretion  of,  100 
Ammonium  salts,  782 
Amoss  and  WoUstein  on  serum  treat- 
ment of  cerebrospinal  meningitis,  564 
Amphoric  breathing,  307 
Amyotonia  congenita,  153 
Amyotrophic  lateral  sclerosis,  526,  527  . 
Amyotrophies.  526 
Amyotrophy,  muscular,  530 
progressive,  526,  530 

Landouzy-Dejerine  type,  530 
of  Erb's  juvenile  type,  530 
scapulohumeral  type,  530 
Anaphylaxis,  708 

pollen,  in  hay-fever,  301 
Anatomy  of  stomach,  172 
Anderson  and  Goldberger  on  measles,  620 
Anemia,  402 

brickmaker's,  247 
functional  heart  murmur  in,  373 
miner's,  247 
pernicious,  408 
blood  in,  409 
lesions,  408 
symptoms,  409 
prognosis,  403 
pseudoleukemia  of  von  Jaksch,  406 

treatment,  407 
secondary,  blood  transfusion  in,  404 
symptoms,  403 
treatment,  404 
Anencephalus,  501 
Anesthetics,  750 
Angina  gangrsenosa,  626 
maligna,  626 

membranous  non-diphtheric,  in  diph- 
theria, 647 
Vincent's,  285 
treatment,  285 


Angioma,  598.     See  also  Noevus. 
Angioneurotic  edema,  570 
Angiosarcoma  of  brain,  502 
Ankylostoma  duodenale,  250 
Antacids  in  milk  adaptation,  63 
Antibodies,  797 
Antipyretic  drugs  as  means  of  relieving 

fever,  746 
Antipyrin  in  whooping-cough,  618 
Antispasmodics    in    spasmodic    croup, 

291 
Antitoxin  syringe,  633 

tetanus,  in  tetanus  neonatorum,  157 
treatment  of  diphtheria,  632 
dosage,  633 
late  injection,  634 
means  of  injection,  633 
promptness,  633 
site  of  injection,  634 
urticaria  after,  635 
Antrum    disease,   staphylococcus  vac- 
cine in,  799 
Anus  and  rectum,  prolapse  of,  258 
treatment,  258 
fissure  of,  260 
inflammation  of,  260 
Aortic  disease,  treatment,  391 

regurgitation,  heart  murmur  in,  372 
stenosis,  murmur  in,  372 
Apathy,  mental,  in  cerebrospinal  men- 
ingitis, 560 
Aphthous  stomatitis,  163 
Appendicitis,  252 

acute,  peritonitis  and,  differentiation, 
254 
pneumonia     and,     differentiation, 
254 
age  incidence,  253 
chronic,  255 

exploratory  incision  in,  254 
interval  operation  in,  255 
intussusception    and,  differentiation, 

254 
leukocytosis  in,  254,  398 
localized  muscle  rigidity  in,  253 
periodic    vomiting    and,    differentia- 
tion, 254 
pleurisy  and,  differentiation,  254 
prognosis,  254 
symptoms,  253 
treatment,  254 
Appetite,  habitual  loss  of,  79-81 
in  pyloric  stenosis,  189 


INDEX 


867 


Archanzelsky    on    tuberculous    menin- 
gitis, 556 
Aretaeus  on  diphtheria,  626 
Arms,   exercise   for,    in   anterior   poHo- 

myehtis,  842 
Arnold  sterilizer,  75 
Arsenic  in  chorea,.  522 
Arsenobenzol      in      acute      hereditary 

syphilis,  685 
Arthritis  deformans,  724 
treatment,  724 
diagnosis,  757 
gonorrheal,  diagnosis,  757 
in  scarlet  fever,  648 
treatment,  656 
rheumatoid,  724 
treatment,  724 
Artificial  feeding,  48 

cow's  milk  for,  49.     See  also  Milk, 

cow's. 
factor  of  environment  in,  48 
needs  of  patient  in,  48 
nutritional  errors  in,  48 
successful,  49 
heat  for  premature  infant,  140 
respiration  in  asphyxia  neonatorum, 
150,  151 
Ascaris  lumbricoides,  247 
Asclepiades  on  diphtheria,  626 
Asphyxia     as     cause     of    convulsions, 
484 
livida,  149 

treatment,  151 
neonatorum,  148 
delayed,  152 

Dew's  method  of  artificial  respira- 
tion in,  150 
diagnosis,  149 
etiology,  148 
Laborde's     method     of     artificial 

respiration  in,  150 
pathology,  148 
prognosis,  149 
prophylaxis,  150 
Schultze's     method     of     artificial 

respiration  in,  150 
symptomatology,  148 
treatment,  150 
pallida,  149 

signs  of  recovery,  151 
Aspiration  in  secondary  pleurisy,  351 
Asthma,  climate  in,  774 
eosinophilia  in,  399 


.\sthmatic  breathing,  307 

bronchitis,  310 

chest,  303 
Astraphobia,  498 
Ataxia,  Friedreich's,  548-550 

hereditary,  548-550 

cerebellar,  exercises  for,  829-841 
spinal,  exercises  for,  829-841 
Atelectasis,  152 
AteHosis,  733 

Athetosis  in  cerebral  paralysis,  517 
Athrepsia,  86.  See  also  Marasmtis. 
Atresia  of  urethra,  469 

of  vagina,  469 
Atrophies,  progressive  muscular,  526 
Atrophy,       infantile,      86.     See      also 
Marasmus. 

of  liver,  acute  yellow,  264 

progressive  spinal  muscular,  526.  See 
also  Micscular  atrophy,  progressive 
spinal. 
Atropin  in  enuresis,  434 
Attendants  in  acute  illness,  134 
Aura  of  epilepsy,  532 
Auscultation,  304 
Austin  on  icterus  neonatorum,  144 
Autoserum  treatment  of  chorea,  523 
Axillary  adenitis,  417 

Babcock  and  Russell  on  proteid  change 

in  centrifugal  cream,  74 
Babcock  milk  test,  54 
Babinski's  phenomenon  in  cerebrospinal 

meningitis,  561 
Baby,  blue,  386 

scales,  41 
Bacillus,  Bordet  and  Gengou,  614 
coil  communis  in  cystitis,  457 

injections  of,  in  cystitis  and  pye- 
litis, 801 
dysenterise,  221 
influenzaj,  670 
Klebs-Loffler,  infection  by,  as  cause 

of  chronic  rhinitis,  269 
of  diphtheria,  627 

persistent  nasal  infection  with,  637 
of  typhoid  fever,  657 
tetanus,  156 

typhoid  fever,  dead,  inoculation  of,800 
Bacteria  as  etiologic  factor  in  hemor- 
rhagic diseases  of  new-born,  158 
harmful,  in  cow's  milk,  50 
harmless,  in  cow's  milk,  50 


868 


INDEX 


Bacteria,  suspension  of,  798 
Bactericidins,  797 
Balanitis,  459 

Barley  jelly,  formula  for,  70 
Barley-water,  dextrinized,  formula  for, 
71 

formulas  for,  70 
Barlow  on  scurvy,  112 
Barthez     and     Rilliet     on     congenital 

laryngeal  stridor,  491 
Basch  on  extirpation  of  thymus  gland, 
424 

on  percussion  of  thymus  gland,  427 
Basin  bath  for  fever,  780 
Baskets  for  early  exercises,  44 
Bassett  and  Duval  on  acute  ileocolitis, 

221 
Bath,  778 

as  means  of  relieving  fever,  746 

basin,  for  fever,  780 

bran,  780 

brine,  780 

cold   sponge,   in  bronchopneumonia, 
341 

compressed-air,  in  emphysema,  829 

for  comfort  in  hot  weather,  780 

for  delicate  children,  126 

for  new-born  infant,  20 

for  sick  child,  781 

hot,  781 

mustard,  780 

soda,  780 

starch,  780 

thermometer,  779 

tub-,  for  fever,  779 
Bauchwitz  on  blood-pressure,  401 
Beach  on  cretinism,  728 
Bed,  position  in,  diagnostic  value,  131 
Bed-sores,  597 
Bed-wetting,  432-434 
Beef  broth,  formula  for,  70 

foods,  proprietary,  73 

scraped,  formula  for,  70 

tape-worm,  249 
Beef -juice,  formula  for,  70 
Behring  on  diphtheria,  626 
Belladonna  in  enuresis,  434 
Beriberi,  740 

atrophic,  741 

dry,  741 

wet,  741 
Bernhard  on  heliotherapy,  366 
Bernhardt  on  scarlet  fever,  643 


Bernheim  on  pyloric  stenosis,  187 
Bezold  on  deafness  in  scarlet  fever,  655 
Bichlorid  of  mercury,  782 
Biedert  on  whooping-cough,  616 
Bier's   hyperemia   in  persistent  simple 

adenitis,  418 
Biggs  on  septic  sore  throat,  286 
Bile-ducts,  congenital  absence,  153 
Billings  on  benzol  in  leukemia,  408 
Binswanger  on  epilepsy,  531 
Birch-Hirschfeld  on  icterus  neonatorum, 

143 
Birth  form  of  cerebral  paralysis,  513 
Birth-mark,  598.     See  also  Ncevus. 
Bismuth  meal  in  ptoses  and  dilatation 
of  stomach  in  older  children,  177 

subnitrate  in  acute  ileocolitis,  224 
Blackader  on  intestinal  cysts  and  diver- 
ticula, 246 
Bladder,  diseases  of,  457 

exstrophy  of,  458 

stone  in,  458  , 
Blanchard  on  hypodermoclysis,  797 
Bleeder's  disease,  411-413 
Blood,  394 

changes  in  hemophilia,  412 

coagulation  time  of,  402 

direct  injection  of,  787 

diseases  of,  394 

findings  in  acute  poliomyelitis,  536 

in  infections  by  intestinal  parasites, 
247 

in  new-born,  394 
specific  gravity,  394 

in  pernicious  anemia,  409 

in  stools,  47 

in  urine,  436 

transfusion,  786 
indications  for,  786 
in  secondary  anemia,  404 
prevention  of  hemolysis  in,  786 

vomiting  of,  182 
Blood-cells,  red,  394 
Blood-pressure  in  children,  401 
Blood-vessels  in  tardy  hereditary  syph- 
ilis, 686 
Blue  baby,  386 
Blumenreich   on  percussion  of  thymus 

gland,  427 
Blundell  on  blood  transfusion,  786 
Board,  window-,  138 
Boils,  573 
Bone-marrow  in  leukemia,  408 


INDEX 


869 


Bones,  changes  in,  in  rachitis,  118,  119 

diseases  of,  diagnosis,  757 

in  tardy  hereditary  syphihs,  687,  688 

turbinated,  hypertrophy  of,  as  cause 
of  chronic  rhinitis,  269 
Bordet  and  Gengou  bacillus,  614 
Bothriocephalus  latus,  249 
Bottle,  nursing-,  47 

nipple  for,  47,  48 
Bouchut  on  icterus  neonatorum,  143 
Bovaird  and  NicoU  on  weight  of  thy- 
mus, 423 
Bovine  tuberculosis,  691 
Bowditch  on  average  weight  of  house- 
clothing,  40 
of  new-born  infant,  40 
Bowels,  136 

evacuation  of,  defective,  237 
Bowles  stethoscope,  309 
Brace  to  prevent  masturbation,  481 
Brain,  cysts  of,  502 

malformations  of,  499 
individual  lobes  of,  501 

sepsis  of,  in  new-born,  147 

tuberculosis  of,  364 

tumors,  502 

tuberculous,  502 

wet-,    in  gastro-enteric  intoxication, 
195 
Bran  bath,  780 
Breast  milk,  analysis,  55 

of  mother,  34 

pigeon-,  302 
Breast-fed  infant,  rachitis  in,  116 

stools  of,  46 
Breast-feeding,  substitute,  48.    See  also 

Artificial  feeding. 
Breast-milk,  31 

analyses  of,  32 

conditions      producing     unfavorable 
effect  on,  30 

examination  of,  32 

proteids  of,  32 
Breast-pump,  English,  35 
Breasts,  caking  of,  treatment,  35,  36 

care  of,  during  weaning,  30 

inflammation  of,  in  new-born,  155 
.  in  young  girls,  422 
Breath  in  cyclic  vomiting,  716 
Breathing,  780.     See  also  Respiration. 

abdominal,  813 

amphoric,  307 

asthmatic,  307 


Breathing,  bronchial,  306 

distant,  305 

of  moderate  intensity,  305 

very  loud,  305 
bronchovesicular,  307 
cavernous,  307 
deep,  in  emphysema,  828 
diminished,  306 
emphysematous,  307 
exaggerated,  306 
exercises,  814 

for  older  children,  815 

for  younger  children,  815 
in  exercise,  806 
mouth-,  in  adenoids,  294 
thoracic,  813 
vesicular,  304,  305 

distant,  305 

exaggerated,  305 
weakened,  306 
Breck  feeder,  141 
Bretonneau  on  diphtheria,  626 
Brickmaker's  anemia,  247 
Brine  bath,  780 
Bromids  in  epilepsy,  534 
Bronchial  breathing,  306 

distant,  305 

of  moderate  intensity,  305 

very  loud,  305 
Bronchiectasis,  344 
Bronchitis,  310 

acute,    bronchopneumonia    and,  dif- 
ferentiation, 336 

spasmodic,  316-320 
asthmatic,  310 
auscultation  in,  311 
bacteriology,  310 
capillary,  316 
chronic,  310 

diagnosis,  311 

treatment,  314 
cough  in,  311 
counterirritation  in,  312 
diagnosis,  311 

differential,  314 
diet  in,  312 
drugs  in,  313 
duration,  311 
fever  in,  310 
in  influenza,  674 
mustard  bath  in,  313 
pathology,  310 
percussion  in,  311 


870 


INDEX 


Bronchitis,  physical  signs,  311 
predisposing  causes,  310 
primary,  310 

pulmonary  tuberculosis  and,   differ- 
entiation, 314 
recurrent,  314 

bathing  in,  316 

depending  on  rheumatic  state,  712 

diet  in,  315 

drugs  in,  315 

treatment,  315 
secondary,  310 

diagnosis,  311 
simple,  310 

spasmodic,  from  direct  irritation,  318 
steam  inhalations  in,  312 
sj^mptoms,  310 
treatment,  311 
types,  310 
Bronchopneumonia,  332 
active  types,  335 
acute  bronchitis  and,  differentiation, 

336 
age  incidence  in,  333 
alcohol  in,  340 
as  cause  of  convulsions,  484 
auscultation  in,  333 
baths  in,  341 
bowels  in,  .337 

caffein  sodiosalicylate  in,  340 
cold  sponging  in,  341 
complications,  336 
counterirritants  in,  338 
diagnosis,  differential,  336 
diet  in,  337 
drugs  in,  339 
duration,  334 
etiology,  332 
fever  in,  treatment,  341 
following  other  diseases,  336 
heart  stimulants  in,  340 
hypodermic  medication  in,  340 
in  influenza,  674 
in  measles,  621 
in  scarlet  fever,  648 
lobar  pneumonia  and,  differentiation, 

336 
mustard  baths  in,  339 

plaster  in,  338 
nitroglycerin  in,  340 
oxygen  in,  342 
palpation  in,  334 
pathology,  333 


Bronchopneumonia,  percussion  in,  334 

physical  signs,  333 

prognosis,  336 

pyrexia  in,  treatment,  341 

rales  in,  333 

respiratory  murmur  in,  333 

sick-room  in,  337 

special  types,  334 

steam  inhalations  in,  338 

strophanthus  in,  340 

strychnin  in,  340 

symptoms,  334 

treatment,  337 

turpentine  in,  338 
Bronchovesicular  breathing,  307 
Brophy's  operation  for  cleft  palate,  169 
Broths,    animal,    in    gastro-enteric    in- 
toxication, 199 

beef,  formula  for,  70 

mutton,  formula  for,  70 
Brown  and  Holt  on  salvarsan  in  syphilis, 

684 
Brown  on  tuberculin  skin  reactions  in 

infancy,  703 
Bruck  on  Wassermann  test  for  syphilis, 

704 
Buckley  on  tinea  tonsurans,  578 
Buhl  and  von  Hecker  on  hemorrhagic 

diseases  of  new-born,  157,  159 
Buhl's  disease,  157 
Bulan  on  siphon  drainage  in  empyema, 

356 
Bulb,  Hess,  in  pyloric  stenosis,  189 
Bulbar  paralysis,  progressive,  527 
Bulkley  on  psoriasis,  597 
Bullock  on  hemophilia,  411 
Butter  on  whooping-cough,  614 
Butyric-acid  test  for  syphilis,  705 
Buxton  on  measles,  619 

Cabot  on  bronchial  breathing,  306 
on  characteristics  of  respiration,  305 
on  leukocytosis  in  peritonitis,  398 
on  pseudoleukemic  anemia,  406 

Caffein     sodiosalicylate     in     broncho- 
pneumonia, 340 
in  lobar  pneumonia,  330 

Caking  of  breast,  treatment,  35,  36 

Calculus,  vesical,  458 

Calmette  on  tuberculosis,  693 

tuberculin  test  for  tuberculosis,  703 

Calomel     fumigations     in     spasmodic 
croup,  290 


INDEX 


871 


Calorimetric  standard,  66 

Cancrum  oris,  166 

Cannon  on  gastric  digestion,  173 

Capacity  of  stomach,  172 

Capillary  bronchitis,  316 

Caput  succedaneum,   cephalhematoma 

and,  differentiation,  143 
Carbon  incapacity  as  cause  of  eczema, 

585 
Carcinoma,  751 
of  brain,  502 
Cardiorespiratory  heart  murmur,  373 
Care  of  teeth,  169 
Caries,  tuberculosis  of  cervical  vertebra, 

278 
Carpenter  and  Gittings  on  coagulation 

time  of  blood,  402 
Carr  on  tuberculosis,  694 
Carrel  on  blood  transfusion,  786 
Carriers,  diphtheria,  627 
Carstanjen  on  blood  in  new-born,  394 

on  transitional  cells,  395 
Carswell   on    pemphigus    neonatorum, 

580 
Casein  of  cow's  milk,  49 
Castor  oil,  782 
Catarrh,  nasal,  269 
Catarrhal  jaundice,  265 
laryngitis,     acute,     287.       See     also 

Spasmodic  croup. 
pneumonia,  332.     See  also  Broncho- 

pneximonia. 
proctitis,  261 
stomatitis,  163 
Catheter  feeding  in  pyloric  stenosis,  193 
Cautley  on  cerebral  paralysis,  514 
on  polycythemia,  401 
on  pseudoleukemic  anemia,  406 
Cavernous  breathing,  307 
Cazal  on  pellagra,  738 
Cecil  on  diabetes  mellitus,  735 
Cells,  transitional,  395 
Centrifugal  cream,  74 
Cephalhematoma,  142 
Cephalogie  epidemique,  557 
Cereal  decoctions  in  gastro-enteric  in- 
toxication, 200 
gruels,  66 

beginning  feeding  of,  67 
for  milk  adaptation,  64 
in  gastro-enteric  diseases,  67 
in  infectious  diseases,  67 
Cerebral  palsies,  513 


Cerebrospinal   fluid    in   anterior   polio- 
myelitis, 536 
in  cerebrospinal  meningitis,  558 
meningitis,  557 
age  incidence,  559 
Babinski's  phenomenon  in,   561 
bacteriologj^,  557 
bowels  in,  560 
cerebrospinal  fluid  in,  558 
complications,  562 
convulsions  in,  560 
diagnosis,  561 

differential,  562 
duration,  562 
ears  in,  560 
emaciation  in,  562 
eyes  in,  560,  562 
Flexner's  serum  in,  563-565 
fontanel  in,  560 
fulminating  cases,  559 
heart  action  in,  560,  562 
Kernig's  sign  in,  561 
mental  apathy  in,  560 
muscle  rigidity  in,  560 
patellar  reflex  in,  562 
pathology,  558 
position  of  patient  in,  560 
respiration  in,  560,  562 
serum  treatment,  563-565 
symptoms,  559 

in  fulminating  cases,  559 
in  recovery  cases,  561 
tache  cer^brale  in,  561 
temperature  in,  560,  562 
transmission,  558 
treatment,  562 
vaccine  treatment,  565 
Certified    milk,     50.     See    also    Milk, 

certified. 
Cervical  hanph-nodes,   tuberculosis  of, 
420 
vertebra,  tuberculous  caries  of,  278 
Chaillon  on  diphtheria,  626 
Chair,  Mosher's  kindergarten,  808 
Chapin  dipper,  57 

on  diet  in  malnutrition,  93 
on  infant  feeding,  51 
Charcot-Marie-Tooth  tj^pe  of  progres- 
sive spinal  muscular  atrophy,  527 
Charcot's  disease,  526 
Cheadle  on  scurv3%  111 
Chemical  agents  as  etiologic  factor  in 
hemorrhagic  diseases  of  new-born,  159 


872 


INDEX 


Cherry  red  spot   in  amaurotic  family 

idiocy,  509 
Chest,  asthmatic,  303 

auscultation  of,  304 

contracted,  302 

defective  expansion  of,  303 

depressed,  302 

diseases  of,  302 

distended,  303 

examination  of,  302 

fixed,  303 

flatness  of,  304 
exercise  for,  839 

funnel,  302 

inspection  of,  302 

palpation  of,  303 

percussion  of,  303 

rachitic,  302 
Chicken  broth,  formula  for,  70 
Chicken-pox,  609-611 
Child,  individual,  treatment  and  care 
of,  139 

necessity  of  method  in  management, 
139 
Chine-cough,  614 
Chink  cough,  614 

Chlorate  of  potash  in  stomatitis,  166 
Chloroform  as  anesthetic,  750,  751 

in  convulsions,  486 
Chlorosis,  405 

Egyptian,  247 
Cholera  infantum,  194.    See  also  Gastro- 
enteric intoxication. 
Cholesteatoma  of  brain,  502 
Chondritis,  fetal,  725 
Chondrodystrophia,  725-727 
Chondromalacia,  725 
Chorea,  518 

anglorum,  518 

antirheumatic  treatment,  521 

arsenic  in,  522 

autoserum  treatment,  523 

chronic  adult,  518 
progressive,  518 

congenital,  518 

diagnosis,  520 

drugs  in,  521 

duration,  520 

electric,  518 

entertainment  in,  521 

etiology,  518 

Fowler's  solution  in,  522 

gravidarum,  518 


Chorea,  habit,  520 

spasm  and,  differentiation,  520 

major,  518 

minor,  518 

posthemiplegic,  518 

prognosis,  520 

recurrence,  520 

rheumatism  and,  relation,  519 

salicylate  of  soda  in,  521 

school  in,  521 

senile,  518 

supplementary  treatment,  523 

symptoms,  519 

treatment,  521 

vulgaris,  518 
Choreic  insanity,  518 
Churchill  on  lymphatic  leukemia,  407 

on  pneumococcus,  321 
Chvostek's  sign  in  spasmophilia,  490 

in  tetany,  495 
Circumcision,  461 

in  phimosis,  460 
Cirrhosis  of  liver,  264 
Clark  and  Flexner  on  acute  poliomye- 
litis, 537 
Clark  on  pyloric  stenosis,  187 
Claw-hand  in  progressive  spinal  mus- 
cular atrophy,  527 
Cleft  palate,  168 

Climate,  change  of,  in  habitual  loss  of 
appetite,  81 
in  influenza,  677 

for  deUcate  children,  127 

in  asthma,  474 

in  digestive  disorders,  774 

in  influenza,  773 

in  malnutrition,  774 

in  nephritis, '  774 

in  pneumonia,  773 

in  pulmonary  tuberculosis,  364 

in  tetany,  497 

in  tuberculosis,  774 

in  whooping  cough,  773 

influence  of,  in  acute  ileocolitis,  226 

therapeutic  value,  773 
Clothing,  effect  of,  on  posture,  807 

for  delicate  children,  128 

for  exercise,  803 

in  acute  illness,  134 

in  eczema,  589 

in  lobar  pneumonia,  328 

in  scarlet  fever,  651 

in  summer,  763 


INDEX 


873 


Clubbed    fingers    in    congenital    heart 

disease,  387,  388 
Coagulation  time  of  blood,  402 
Codein  in  whooping  cough,  618 
Cod-liver  oil  in  rachitis,  121 
Coin  test  in  pneumothorax,  346 
Coit  on  milk  commission,  51 
Cold  air  in  acute  illness,  134 
in  lobar  pneumonia,  328 

as  a  therapeutic  agent,  785 

compresses     in     spasmodic      croup, 
290 

douche,  779 

in  head,  267 

sponging  in  fever,  776 
Cole  on  enlarged  thymus,  427 
Colic,  214-216 

counterirritants  in,  776 
Colitis  in  influenza,  674 

mucous,  229 
Colon  flushing,  795 
technic,  796 

idiopathic  dilatation  of,  230 

irrigation,  793 

in  acute  enteric  intoxication,  203 
in  acute  ileocolitis,  225 
in  chronic  ileocolitis,  229 
technic,  794 
Colonic  feeding,  83 
Colony  management  in  epilepsy,  534 
Comby  on  blood-pressure  in  contagious 
diseases,  402 

on  cyclic  vomiting  in  chronic  appen- 
dicitis, 255 

on  pseudoleukemic  anemia,  406 
Complement-fixation  test  for  syphilis, 

705 
Compressed-air    bath    in    emphysema, 

829 
Compresses,  cold,  in  spasmodic  croup, 

290 
Concepts,  imperative,  498 
Condensed  milk  in  malnutrition,  95 

sweetened,  in  marasmus,  91 
Congenital  syphilis,  678,  684.     See  also 

Syphilis,  acute  hereditary. 
Congenitally  weak  infant,  140 
Congestion  stage  in  lobar  pneumonia, 

321 
Consanguinity,  744 

Consciousness,    beginning    of,    in  new- 
born infant,   43 
Constipated  stools,  hard,  46 


Constipation,  236 
exercise  in,  843 
in  bottle-fed,  239-241 
in  chronic  ileocolitis,  treatment,  229 
in  mechanical  intestinal  disturbances, 

treatment,  213 
in  mother  in  maternal  nursing,  treat- 
ment, 25 
in  mucous  coUtis,  treatment,  230 
in  nurslings,  238 
in  older  children,  241 
diet  in,  242 

after  fifth  year,  243 
after  second  year,  242 
drugs  in,  244 
etiology,  241 

from  mechanical  obstruction,  241 
local  causes,  241 

measures  in,  243 
regular  habits  in,  241 
in  pyloric  stenoses,  188 
in  tardy  malnutrition,  102 
obstinate,     after     acute     ileocolitis, 
treatment,  227 
treatment,  244 
Contagious  diseases,  608 

precautions  for  physician  in,  609 
Contracted  chest,  302 
Convalescence    in    acute    endocarditis, 
383 
in  erj^sipelas,  584 
in  myocarditis,  385 
Convulsions,  483 

asphyxia  as  cause,  484 

bronchopneumonia  as  cause,  484 

chloroform  in,  486 

dentition,  485 

diet  in,  486 

enlargement    of    thymus    gland    as 

cause,  484 
enterocolitis  as  cause,  484 
etiology,  483 

gastro-intestinal  causes,  483 
heredity  as  cause,  484 
hypodermic  medication  in,  486 
in  acute  diffuse  nephritis,  444 
in  cerebrospinal  meningitis,  560 
in  dentition,  170 
intestinal  parasites  as  cause,  484 
inward,  485 
manifestations,  485 
of  toxic  origin,  484 
phimosis  as  cause,  484 


874 


INDEX 


Convulsions,  prognosis,  485 

rachitis  as  cause,  483 

repetition,  485 

sedatives  in,  486 

tetam'  as  cause,  485 

treatment,  486 

uremic,  484 
Cooke    and    Hamilton    on    gonococcus 

vaccine,  800 
Cool  pack,  "777 

Cord,  umbilical,  care  of  stump,  41 
Corn-bread  disease,  738 
Corpuscles,  white,  normal,  394 
Corwin  on  starch  digestion,  68 
Coryza,  267 
Cough,  272 

adenoids  as  cause,  272 

chink,  614 

habit,  272 

in  bronchitis,  311 

in  influenza,  672 

in  measles,  620 
treatment,  623 

king's,  614 

nervous,  272 

persistent,  272 

pertussis  as  cause,  273 

stomach,  272 

teething,  272 

tracheal,  273 

tuberculosis  as  cause,  273 

types,  272 
Counterirritants,  775 
Cow's  milk.     See  also  Milk,  cow's. 
Cracked  nipples,  34 

Craig  on   complement-fixation  test  in 
syphilis,  705 

on  malaria,  667 
Craniectomy  in  microcephalus,  500 
Craniotabes  in  rachitis,  118,  119 
Cray  on  starch  digestion  in  infant,  68 
Cream,  73 

and  milk  mixtures,  56-58 

centrifugal,  74 

gravity,  56,  73 
Creosote,  782 
Cretinism,  727 

acquired,  730 

rachitis  and,  differentiation,  120 

thyroid  treatment,  731-733 
Cretinoid  idiocy,  727.     See  also  Cretin- 
ism. 
Crile  on  blood  transfusion,  786 


Crocker  on  tinea  tonsurans,  576 
Croup,  spasmodic,  287,  487.     See  also 

Spas7nodic  croup. 
Cruveilhier   on   ulcers   in   stomach   in 

melena,  158 
Crying,  44 

Cummins  on  trichiniasis,  251 
Curds  in  stools,  47 
Curets,  adenoid,  299 
Curling  on  cretinism,  728 
Curvature  of  spine,  lateral,  820.     See 

also  Scoliosis. 
Cushing  on  dyspituitarism,  428  " 
Cutaneous  sensibility  in  new-born  in- 
fant, 42 
tuberculin  test  in  tuberculosis,  701 
Cyclic  diarrhea,  719 
vomiting,  715 
breath  in,  716 
diagnosis,  differential,  717 
drugs  in,  717 
etiology,  715 
prognosis,  717 
sodium  bicarbonate  in,  718 
symptoms,  716 
treatment  in  interval,  717 

of  acute  attack,  718 
with  acidosis,  714,  715 
Cyclops,  501 
Cystitis,  457 

injection  of  Bacillus  coli  in,  801 
Cysts,  intestinal,  246 
of  brain,  502 

parasitic,  502 
of  kidney,  441 
Czerny   and   Keller  on   excessive   am- 
monia excretion,  100 
on  tetany,  493 

Dactylitis,  699 

differentiation  of  types,  701 

syphilitica,  699 

tuberculosa,  699 
Dana  on  congenital  ataxias,  830 

on  porencephalus,  501 
Dance,  St.  Vitus',  518.     See  also  Chorea. 
Danielson  and  Mann  on  cerebrospinal 

meningitis,  557 
Dare  on  hemoglobin  in  anemia,  404 
Davis  on  influenza,  671 

on  whooping-cough,  615 
Days  to  go  out-of-doors,  762 
Day-terrors,  470 


INDEX 


875 


Deaderick  and  Thompson  on  pellagra, 

740 
Deafness,  600 
Decubitus,  597 
Deficiency,     mental,     503.     See     also 

Mental  deficiency. 
Deformities  in  rachitis,  treatment,  122 
Deformity  following  untreated  cases  of 

empyema,  356 
D6jerine  on  epilepsy,  531 
Delayed  asphyxia,  152 
Delicate  child,  122 
bathing,  126 
care  of,  123-129 
climate  in  care  of,  127 
clothing  for,  128 
diet  for,  124 

after  first  year,  125 
effect   of   removal   of   tonsils   and 

adenoids  on,  301 
entertainment,  128 
exercise,  128 
fresh  air,  126 
mid-day  nap,  128 
nursery,  127 
sleep  for,  127 
treatment,  123 
weighing,  124 
Delirium  in  lobar  pneumonia,  324 
Dementia  prsecox,  499 
Dent  on  pyloric  stenosis,  187 
Dentition,  170 

as  cause  of  convulsions,  484 
of  digestive  disorders,  170 
convulsions,  170,  485 
disturbances  of,  170 
Denys  on  blood  transfusion,  786 

on  phagocytosis,  797 
Depressed  chest,  302 
fracture    of    skull,    cephalhematoma 

and,  differentiation,  143 
nipples,  35 
Dermatitis  in  pellagra,  739 
des  Gabets  on  blood  transfusion,  786 
Desquamation     in     German    measles, 
625 
in  scarlet  fever,  646 
Detre's  differential  cutaneous  reaction 

in  tuberculosis,  702 
Development,  abnormal,  of  child,  123 

normal,  of  child,  123 
Dew's  method   of  artificial  respiration 
in  asphyxia  neonatorum,  150 


Dextrinized  barley-water,  formula  for, 

71 
Diabetes  insipidus,  734 

mellitus,  735-737 
Diagnosis,  130 
by  inspection,  131 
during  sleep,  132 
Diaper,  ammoniacal,  100 
Diaphoresis  as  means  of  relieving  fever, 

746 
Diaphragmatic  hernia,  757 
Diarrhea,  cyclic,  719 
in  lobar  pneumonia,  324 
in  mechanical  intestinal  disturbances, 

treatment,  214 
in  typhoid  fever,  treatment,  664 
summer,  instructions  in,  767 
Diarsenol  in  acute  hereditary  syphilis, 

685 
Diesophagus,  171 
Diet  after  first  year,  102 
after  sixth  year,  108 
common  errors  in,  110 
for  delicate  child,  124,  125 
from  first  to  sixth  year,  105 
in  acute  diffuse  nephritis,  445 
salt-free,  446 
endocarditis,  381 
ileocolitis,  227 
gastric  indigestion,  174 
illness,  135 

infective  meningitis,  552 
in  bronchitis,  312 
in  bronchopneumonia,  337 
in  chronic  ileocolitis,  228 

valvular  disease  of  heart,  391 
in  colic,  215 

in  constipation  in  older  cliildren,  242 
after  fifth  year,  243 
after  second  year,  242 
in    convalescence    from    acute    ileo- 
colitis, 226 
in  convulsions,  486 
in  diabetes  mellitus,  737 
in  diphtheria,  635 
in  eczema,  588 
in  epilepsy,  534 
in  fissure  of  amis,  261 
in  gastro-enteric  intoxication,  198 

after  first  year,  200 
in  habit  spasm,  524 
in  habitual  loss  of  appetite,  80 
in  icterus,  265 


876 


INDEX 


Diet  in  illness,  109 
art  of,  109 
reduction  of  food  strength,  109 

in  laryngismus  stridulus,  489 

in  malnutrition,  93 

in  marasmus,  88,  90 

in  maternal  nursing,  24 

in  measles,  622 

in  mucous  colitis,  230 

in  obesity,  752 

in  pulmonary  tuberculosis,  364 

in  pyloric  stenosis,  192 

in  rachitis,  120 

after  first  year,  121 

in  recurrent  bronchitis,  315 

in  rheumatism,  710 

in  scarlet  fever,  651 

in  scurvy,  114 

in  second  summer,  105 

in  stomatitis,  165 

in  tardy   malnutrition   of   syphilitic 
origin,  690 

in  typhoid  fever,  661 

of  premature  infants,  141 

proteid,  in  tetany,  497 

schedule  for  feeding  after  first  year, 
106-108 

table  of  quantities,  111 
Digestion,  gastric,  172 

stomach,  duration  of,  173 
Digestive  disorders,  climate  in,  774 

from  dentition,  170 
Digitalis,  783 

in  chronic  valvular  heart  disease,  392 

in  lobar  pneumonia,  330 
Dilatation,  congenital,  of  esophagus,  171 

of  colon,  idiopathic,  230 

of  stomach,  chronic,  176 
in  older  children,  177-180 
vomiting  from,  219 
Diminished  breathing,  306 
Diphtheria,  625 

age  incidence,  626 

antitoxin  treatment,    632.     See  also 
Antitoxin  treatment  of  diphtheria. 

bacillus  of,  627 

bacteriology,  627 

carriers,  627 

diet  in,  635 

heart  stimulants  in,  636 

history,  625 

immunization  in,  634 

in  scarlet  fever,  648 


Diphtheria,  incubation  period,  630 
intubation  in,  638-642 
laryngeal,  636 
leukocytosis  in,  400 
multiple  neuritis  after,  542 

treatment,  545 
nasal,  637 

acute  rhinitis  and,  differentiation, 

267 
chronic,  637 
pathology,  630 
predisposition,  626 
quarantine  in,  634 
remedial  measures  in,  635 
Schick  test  in,  627-630 
susceptibility  to,  627 
tonsillar,  tonsillixis  and,   differentia- 
tion, 281 
transmission,  626 
Diplococcus    intracellularis    of    Weich- 
selbaum,  557 
pneumonise,  321 
Dipper,  Chapin,  57 
Diseases,  contagious,  608 

precautions  for  physician  in,  609 
transmissible,  608 

through  association,  608 
intermediary,  608 
Disorders  of  nutrition,  86 
Dispensary  infants  and  children,  rules 

for  summer  care,  765 
Distended  chest,  303 
Diverticula,  intestinal,  congenital,  246 
Dochez,  Draper  and  Peabody  on  acute 
poliomyelitis,    536,    538,    539, 
541 
on  blood  findings  in  poliomye- 
litis, 398 
Dochez  on  blood  in  acute  poliomyelitis, 

536 
Dohle  on  blood  findings  in  scarlet  fever, 
399 
on  scarlet  fever,  643 
Dopter  on  parameningococcus,  558 
Double  empyema,  359 
Douche,  cold,  779 

Douglas  and  Wright  on  opsonins,  797 
Dover's  powder  in  acute  ileocolitis,  224 
Downes  on  surgical  treatment  of  pyloric 

stenosis,  192 
Drainage,  siphon,  in  empyema,  356 
Draper  and  Peabody  on  blood  in  acute 
poliomyelitis,  536 


INDEX 


877 


Draper,  Peabody  and  Dochez  on  acute 
poliomyelitis,  536,  538,  539,  541 
s    on  blood  findings  in  poliomyelitis, 
398 
Dried-milk  foods,  proprietary,  72 
Drinking  of  water  in  acute  illness,  134 
Dromomania,  498 
Drop  jaw  in  adenoids,  295 
Drugs,  847 

counterirritant,  775 

dosage,  847 

for  external  use,  859 

for  internal  use,  847 

nauseating,  781 

unpalatable,  781 
Dry  heat,  785 
Dubini's  disease,  518 
Duchenne-Aran's  disease,  526,  527 
Duke  on  hemorrhagic  diseases  of  new- 
born, 160 
Dulness  of  chest,  304 

tympanitic,  304 
Duodenal  ulcer,  184 
Dupre  on  meningismus,  565 
Duval  and  Bassett  on  acute  ileocolitis, 

221 
Dwarfism,  733 
Dwarfs,  733 
Dyer  on  pellagra,  740 
Dysentery,  220.      See    also    Ileocolitis, 

acute. 
Dyslalia,  525 
Dyspituitarism,  428 
Dystrophy  adiposogenitalis,   428 

muscular,  primary,  530 

Ear  changes  in  tardy  hereditary  syphi- 
lis, 686 

diseases  of,  600 
Earache,  600 

in  acute  otitis,  602 
Ears  in  cerebrospinal  meningitis,  560 

in  measles,  care  of,  623 
Eberth's  bacillus  of  typhoid,  657 
Eczema,  584 

age  incidence,  585 

bathing  in,  589 

carbon  incapacity  as  cause,  585 

clotliing  in,  589 

eosinophilia  in,  399 

etiology,  584 

euresol  in,  589 

feeding  in,  588 


Eczema,  Herty  mask  in,  591 
in  older  children,  591 
bathing  in,  595 
etiology,  592 
prognosis,  594 
symptoms,  593 
treatment,  594 
intertrigo,  590 
local,  595 

local  irritation  as  factor,  586 
neurotic,  593 
physical  condition  in,  585 
prognosis,  586 
reflex,  593 
seborrheic,  595 
strait-jacket  in,  591 
symptoms,  586 
toxic  origin,  585 
traumatic,  treatment,  589 
treatment,  586 
Edema,  angioneurotic,  570 
Edgar  on  treatment  of  asphyxia  neona- 
torum, 150 
Effusion,  pleurisy  with,  349 

pleuritic,  in  lobar  pneumonia,  327 
purulent,    pleurisy    with,    351.     See 
also  Empyema. 
Egg-water,  formula  for,  70 
Egyptian  chlorosis,  247 
Ehrlich   on  splenomyelogenous   leuke- 
mia, 407 
Eisenberg  on  icterus  neonatorum,  144 
Eiweiss  milk,  65 

in  acute  ileocohtis,  224 
in  gastro-enteric  intoxication,  201 
Electric  chorea,  518 

irritability  in  tetanus,  495 
reactions  in  acute  poliomyeUtis,  540 
in  cerebral  paralj'sis,  516 
in  multiple  neuritis,  544 
Electricity  in  acute  poliomyelitis,  541 
Elimination's  means  of  relieving  fever, 

746 
Elliott  on  seborrhea  intertrigo,  596 
Emaciation  in  cerebrospinal  meningitis, 

562 
Emerson  on  blood   findings  in  scarlet 
fever,  400 
on  chondrodj'strophia,  725 
on  leukocytosis  in  measles,  400 
in  meningitis,  398 
in  scarlet  fever,  400 
in  whooping-cough,  399 


878 


INDEX 


Emerson   on   polymorphonuclear   neu- 
trophiles,  395 
on  splenomyelogenous  leukemia,  407 
on  pseudoleukemic  anemia,  406 
Emphysema,  346 
auscultation  in,  347 
compressed-air  bath  in,  829 
deep  breathing  in,  828 
development  of  accessory  muscles  of 

expiration  in,.  829 
exercise  in,  827-829 
Gerhardt's  exercise  in,  849 
McKenzie's  exercise  in,  828 
of  mediastinum,  347 
pathology,  346 
percussion  in,  347 
prognosis,  347 

rarefied  air  apparatus  in,  829 
respiratory  exercises  in,  828 
Satterthwaite's   method  of   artificial 

respiration  in,  828 
subcutaneous,  347 

Sylvester's  method  of  artificial  res- 
piration in,  828 
symptoms,  346 
treatment,  347 
Emphysematous  breathing,  307 
Empyema,  351 

after  lobar  pneumonia,  353 

age  incidence,  351 

bacteriology,  351 

counterirritants  in,  776 

deformity  following  untreated  cases, 

356 
diagnosis,  354 

differential,  354 
double,  359 
encysted,    as   cause   of   elevation  of 

temperature,  749 
etiology,  351 
exercises  for,  793,  794 
in  lobar  pneumonia,  325 
leukocytosis  in,  397 
malaria  and,  differentiation,  355 
necessitatis,  360 
pathology,  352 

pleurisy  and,  differentiation,  354 
pneumonia  and,  differentiation,  354 
pulmonary  tuberculosis   and,  differ- 
entiation, 355 
staphylococcus  vaccine  in,  797 
Sylvester's  method  of  artificial  res- 
piration in,  825 


Empyema,  symptoms,  352 
treatment,  355 

typhoid  iever  and,  differentiation,  355 
Encephalocele,  499 

cephalhematoma  and,  differentiation, 

143 
hydrocephalus    and,    differentiation, 
143 
Endocarditis,  acute,  377 
age  incidence,  378 
antirheumatic  treatment,  382 
auscultation  in,  380 
bacteriology,  378 
convalescence  in,  383 
diagnosis,  379 
diet  in,  381 

diagnosis,  differential,  380 
drugs  in,  381 
etiology,  378 
ice-bag  in,  381 
inspection  in,  379 
palpation  in,  379 
pathology,  378 
percussion  in,  380 
prognosis,  380 
prolonged  inactivity  in,  381 
recurrence,  382 
rest  in  bed  in,  380 
symptomatology,  379 
treatment,  380 
in  scarlet  fever,  648 
malignant,  378 
prognosis,  380 
Enema,  nutrient,  83 

amount  of  nourishment,  85 
method  of  giving,  83 
nourishment  not  to  be  used,  84 

to  be  used,  85 
peptonized  milk  for,  68 
Enemas  in  colic,  215 

in  constipation  in  nurslings,  239 
Engel  on  leukocytosis  in  diphtheria,  400 

on  pyloric  stenosis,  187 
English  breast-pump,  35 
Enteric  intoxication,  acute,  201-203 
Enterocolitis  as  cause  of  convulsions, 

484 
Enuresis,  432-434 

of  nervous  origin,  433 
Environment  and  heredity,  743 

as  factor  in  nutrition  and  growth  of 
new-born  infant,  17 
in  artificial  feeding,  48 


INDEX 


879 


Eosinophiles,  395 

Eosinophilia   from   parasitic   infection, 
399 

in  asthma,  399 

in  congenital  syphilis,  399 

in  eczema,  399 
Eosinophilic  myelocytes,  395 
Epidemic  parotitis,  611-613 
Epilepsy,  531 

aura  of,  532 

bromids  in,  534 

care  of  bowels  in,  534 

colony  management,  534 

diagnosis,  533 

diet  in,  534 

drugs  in,  534 

grand  mal,  532 

in  birth  form  of  cerebral  paralysis,  515 

in  cerebral  paralysis,  517 

prognosis,  533 

treatment,  533 

types,  532 
Epiphysitis,  acute,  in  acute  hereditary 

syphilis,  681 
Epispadias,  464 

Epstein  on  icterus  neonatorum,  143 
Erb  on  progressive  amyotrophy,  530 
Erb's     juvenile     tj^pe     of     progressive 
amyotrophy,  530 

paralysis,  547 
Erysipelas,  581 

complications,  582 

convalescence  in,  584 

etiologj^,  582 

ichthyol  in,  583 

prognosis,  582 

stimulants  in,  584 

streptococcus  vaccine  in,  800 

symptoms,  582 

treatment,  583 
Erythema  intertrigo,  590 

multiforme,  581 

nodosum,  580 
Escherich  on  tetany,  492,  495 
Esophagotracheal  fistula,  171 
Esophagus,  absence  of,  171 

congenital  dilatation  of,  171 

congenital  stenosis  of,  171 

diseases  of,  162 

division  of,  171 

malformation  of,  171 

reduplication  of,  171 
Ether  as  anesthetic,  750,  751 


Ethyl  chlorid  as  anesthetic,  751 
Euresol  in  eczema,  589 
Evaporated  milk  in  malnutrition,  96 
Ewing  on  leukocytosis  in  measles,  400 
Exaggerated  breathing,  306 
Examination,  130 

first,  132 

of  urine  in  acute  illness,  135 

of  throat,  271 
Exercise,  accuracy  of  execution,  804 

active,     elevation     of     temperature 
from,  747 

adaptation  to  practical  ends,  806 

attention  to  general  health  in,  805 

breathing,  806,  814 
for  older  children,  815 
for  younger  children,  815 

clothing  for,  803 

concentration  in,  805 

conditions  necessary  for,  803 

cooperation  in,  806 

double  mirrors  during,  772 

duration,  804 

early,  baskets  for,  44 

examination  before,  803 

for  acute  poliomyelitis,  841 

for   arms  in  anterior  poliomy  elitis, 
842 

for  delicate  children,  128 

for  emphysema,  827-829 

for  empyema,  793,  794 

for  flat  chest,  815 

for  Friedreich's  ataxia,  830,  841 

for  general  circulation  in  constipa- 
tion, 844 

for  hereditary  cerebellar  ataxia,  829- 
841 
spinal  ataxia,  829-841 

for  kyphosis,  817 

for  nursing  mother,  25 

for  round  shoulders,  817 

for  scoliosis,  822 

for    speech    in    congenital    ataxias, 
840 

for  upper  limbs  in  congenital  ataxias, 
840 

forms,  804 

frequency,  804 

Gerhardt's,  in  emphysema,  849 

in  acute  poliomyelitis,  542 

in  bad  posture,  809 

in  constipation,  843 

in  flat-foot,  844-846 


880 


INDEX 


Exercise  in  obesity,  752 

in  talipes  planus,  844-846 

ladder,  in  congenital  ataxias,  837 

McKenzie's,  in  emphysema,  828 

modification,  805 

Naunyn's,  for  empyema,  825 

overwork  in,  805 

passive,  for  constipation,  844 
in  anterior  poliomyelitis,  842 

pen,  767 

posture  in,  806 

prescription  of,  804 

respiratory,  for  emphysema,  828 

rest  in,  805 

room  temperature  for,  803 

rules  for,  803 

shot-bag,  in  bad  posture,  811" 

static,  for  bad  posture,  811 

temporary  discontinuance,  805 

with  resistance,  in  constipation,  844 
Exhaustion,  gavage  in,  792 
Expansion,  defective,  of  lungs,  303 
Expectorants     in     spasmodic      croup, 

289 
Exstrophy  of  bladder,  458 

operative  treatment,  459 
Eye  changes  in  tardy  hereditary  syphilis, 

686,  688 
Eyes,  care  of,  in  measles,  622,  623 

in  cerebrospinal  meningitis,  560,  562 

in  measles,  620 

Face,  expression  of,  in  adenoids,  295 

myopathic,  531 
Facial  deformity,   absence  of,  in  ade- 
noids, 295 

paralysis,  546 
Faucial  tonsils,  279 
Fagge  on  cretinism,  727,  728 
Falling  sickness,  531 
Family  idiocy,  amaurotic,  507-509 
Fat  of  modified  cow's  milk,  56 
Fatty  change  in  liver,  264 
Faucitis,  273 

treatment,  274 
Faught  sphygmomanometer,  401 
Fears,  morbid,  498 
Feces.     See  StooU-. 

incontinence  of,  232 
treatment,  233 
Feeder,  Breck,  141 

Feeding,   artificial,    48.     See  also  Arti- 
ficial feeding. 


Feeding,    breast-,  substitute,  48.     See 
also  Artificial  feeding. 
by  inunction,  82 

catheter,  in  pyloric  stenoses,  193 
colonic,  83 

forced,  790.     See  also  Gavage. 
frozen  milk,  78 
hypodermic,  82 
malt-soup,  64 

in  marasmus,  94 
mixed,  29 

of  delicate  child,  124,  125 
over-,  110 
rectal,  83 

amount  of  nourishment,  85 
in  acute  illness,  136 
method  of  giving,  83 
nourishment  not  to  be  used,  84 
to  be  used,  85 
scientific,  78 
starch-,  66 

stomach-,  substitutes  for,  81 
substitute,  Chapin  dipper  for,  57 
ingredients  required  for,  72 
number  of  feedings,  58-61 
table  of  quantities,  111 
top-milk,  59 
whey-,  64 

in  malnutrition,  94 
Feeling,  beginning  of,  in  new-born  in- 
fants, 43 
Feer  on  pyloric  stenoses,  187 
Female  genitals,  diseases  of,  465 
Fetal  chondritis,  725 

rickets,  725 
Fever,  745 

as  an  indication,  745 
basin  bath  for,  780 
in  acute  otitis,  602 

retropharyngeal  abscess,  277 
in  bronchopneumonia,  treatment,  341 
cold  sponging  in,  776 
in  lobar  pneumonia,  treatment,  329 
methods  of  relieving,  746 
periodic,  720 
rheumatic,  721 
tub-baths  for,  779 
Fibroma  of  brain,  502 

of  kidney,  438 
Fi^vre  C(5r6brale,  557 
Fildes  on  hemophilia,  411 
Finger-sucking,  478 
Finger-tips,  picking  and  rubbing,  478 


INDEX 


881 


Finkelstein  and  Meyer's  Eiweiss  milk, 
65 

on  icterus  neonatorum,  144 

on   leukocytosis    in   gastro-enteritis, 
399 

on  pyloric  stenosis,  188 

on  spasmophilia,  489 
Fischl  on  tetany,  492 
Fish  tape-worm,  249 
Fissures  at  angle  of  mouth,  168 

in  acute  hereditary  syphilis,  681 

of  anus,  260 

of  lips,  167 
Fissured  nipples,  34 
Fistula,  esophagotracheal,  171 
Fixed  chest,  303 
Flat  chest,  304,  815 
Flat-foot,  exercises  for,  844-846 

massage  in,  845 
Fleishmann  on  capacity  of  stomach,  184 
Flexner  and  Clark  on  acute  poliomye- 
litis, 537 
Flexner  and  Jobling  on  antimeningo- 
coccus  serum,  800 
on  cerebrospinal  meningitis,  557 
Flexner  and  Lewis  on  acute  poliomye- 
litis, 537 
Flexner    and    Noguchi    on    cause    of 

anterior  poliomyelitis,  535 
Flexner  on  acute  poliomyelitis,  536,  537 
Flexner,  Peabody  and  Draper  on  acute 

poliomyelitis,  536 
Flexner's  serum  in  cerebrospinal  men- 
ingitis, 563-565 
Floor  of  nursery,  36 
Floyd  and   Morse   on  bacteriology  of 

chorea,  519 
Flushing,  colon,  795 

technic,  796 
Fochsinger  on  tardy  hereditary  syphilis, 

686 
Folli  on  blood  transfusion,  786 
Follicular  tonsillitis,  acute,  280 
Fontanel   in  cerebrospinal   meningitis, 

560 
Food,  advantage  of  knowledge  of  com- 
position, 103 

allergy,  79 

dried-milk,  proprietary,  72 

elements,  function  of,  103 

formulas,  70 

general  properties,  102 

idiosyncrasy  to,  79 
56 


Food,  ingredients,  103 
laxative  agents  in,  in  constipation  in 

bottle-fed,  240 
malted,  in  constipation  in  nursUngs, 

239 
proprietary,  71 

addition  of  fresh  cow's  milk,  73 
beef,  73 
retention  in  pyloric  stenoses,  188 
selection  and   preparation  for   new- 
born infant,  19 
selection  of,  104 

strength,  reduction  in,  in  illness,  109 
in  summer,  763 
Foot,  flat-,  exercises  for,  844,  846 

massage  in,  845 
Forced  feeding,  790.     See  also  Gavage. 
Foreign    bodies    as    cause    of    chronic 
rhinitis,  270 
in  larynx,  292 
swallowed,  769 
Formulas,  food,  70 
Fournier  on  tardy  hereditary  syphilis, 

685 
Fowler  on  leukocytosis  in  appendicitis, 

398 
Fowler's  solution  in  chorea,  522 
Fox  on  cretinism,  728 
Fracture   of   skull,    depressed,    cephal- 
hematoma and,  differentiation,  143 
Franck  on  icterus  neonatorum,  143 
Frankel's  pneumococcus,  321 
Frapoli  on  leprosy,  738 
Freeman   on   intestinal    infantilism   of 
Herter,  231 
on  rickets,  115 
pasteurizer,  75 
Fremitus,  vocal,   in  lobar  pneumonia, 

327 
Friedlander's  pneumobacillus,  321 
Friedleben  on  weight  of  thymus,  423 
Friedreich's  ataxia,  548-550 

exercises  for,  830,  841 
Fresh  air  for  new-born  infant,  19 
for  premature  infant,  141 
in  habitual  loss  of  appetite,  80 
in  measles,  624 
in  whooping-cough,  619 
Freund  on  pyloric  stenosis,  186,  187 
Frohlich  and  Muenier  on  leukocytosis 

in  whooping-cough,  400 
Frohlich 's   dystrophy  adiposogenitalis, 
42« 


882 


INDEX 


Frozen  milk,  78 

Fumigations,     calomel,     in    spasmodic 

croup,  290 
Functional  heart  murmurs,  370 
Funicular  hydrocele,  463 
Funnel  chest,  302 
Furniture,  effect  of,  on  posture,  808 

of  nursery,  37 
Furunculosis,  573 

staphylococcus  yaccine  in,  799 

treatment,  local,  573 
constitutional,  574 


Gaffky  on  Bacillus  typhosus,  657 
Gait,     waddling,     in    pseudornuscular 

hypertrophy,  531 
Galen  on  diphtheria,  626 
Ganghofner  on  tetany,  492 
Gangrene,  pulmonary,  360 
Gant  on  intestinal  cysts,  246 
Gardner  on  treatment  of  bronchiectasis, 

345 
Gastric  digestion,  172 
hemorrhage,  182 
indigestion,  acute,  173 

chronic,  175 
motility,  173 
Gastritis,  acute,  173 
chronic,  175 
in  influenza,  674 
Gastro-enteric  diseases,  cereal  gruels  in, 
67 
intoxication,  194 
acidosis  in,  193 
acute,  193 

types,  194 
animal  broths  in,  199 
cereal  decoctions  in,  200 
condensed  milk  in,  200 
diet  in,  198 
drugs  in,  197 
Eiweiss  milk  in,  201 
evaporated  milk  in,  200 
feedings  after  first  year  in,  200 
hypodermoclysis  in,  198 
milk  substitutes  in,  196 
pathology,  195 
proteid  milk  in,  201 
re-infection  in,  199 
skimmed  milk  in,  198 
symptoms,  195 
termination,  197 


Gastro-enteric  intoxication,  treatment, 
196 

urine  in,  195 
wet-brain  in,  195 
wet-nurse  in,  199 
Gastro-enteritis,  leukocytosis  in,  399 
Gastro-intestinal  causes  of  convulsions, 
483 
symptoms  in  scarlet  fever,  659 
Gaucher  type  of  splenomegaly,  263 
Gavage,  790 
in  exhaustion,  792 
in  lobar  pneumonia,  331 
in  malnutrition,  792 
in  multiple  neuritis,  546 
in  narcosis,  792 
in  obstinate  vomiting,  791 
in  severe  illness,  792 
peptonized  milk  for,  68 
stomach-tube  for,  791 
Gengou  and  Bordet  bacillus,  614 
Genitals,  female,  diseases  of,  465 

male,  diseases  of,  459 
Geographic  tongue,  167 
Gerhardt's     exercise     in     emphysema, 

849 
German  measles,  624 
Getzowa  on  cretinism,  728 
Ghou  on  pulmonary  tuberculosis,  361 
Giant  hives,  570 
Gibney  on  scurvy,  114 
Gilford  on  true  dwarfism,  733 
Gittings  and  Carpenter  on  coagulation 

time  of  blood,  402 
Gland,  thymus,  423 

enlargement  of,  424.     See  also  Status 
lymphaticus. 
Glands,  tuberculous,  420 
Glandular  fever,  419 

system,  diseases  of,  415 
Glioma  of  brain,  502 
Gliosarcoma  of  brain,  502 
Glisson  on  rickets,  115 

on  scurvy.  111 
Globus  hystericus  in  hysteria,  474 
Glycosuria,  437 

Gofflsey  on  tuberculous  adenitis,  420 
Goldberg  on  pellagra,  738 
Goldberger  and  Anderson  on  measles, 

620 
Gonococcus  vaccine,  800 
Gonorrhea  in  male,  464 
in  nursery  maids,  38 


INDEX 


883 


Gonorrheal  arthritis,  diagnosis,  757 

vulvovaginitis,  466 
Goodman  on  chorea,  523 
Gowers  on  brain  tumors,  502 

on  Friedreich's  ataxia,  549 
Graham    on   hemorrhagic    diseases    of 

new-born,  160 
Grand  mal  type  of  epilepsy,  532 
Granuloma,  umbilical,  154 
Gravity  cream,  56,  73 
Gray  hepatization  in  lobar  pneumonia, 

321 
Greger  on  leukocytosis,  396 
Grip,  670.     See  also  Influenza. 
Grooves,  Harrison's,  in  rachitis,  118 
Growing  pains,  709 
Gruel  flours,  percentage,  formulas  for, 

70,  71 
Gruels,  cereal,  66 

for  milk  adaptation,  64 
Gull  on  cretinism,  727 
Gumma  of  brain,  502 
Gymnastic  therapeutics,  803.     See  also 

Exercise. 
Gyrospasm,  472 

Habits,  477 

bad,  correction  of,  478 
Habit  chorea,  520 

cough,  272 

spasm,  524  .    , 

Habitual  loss  of  appetite,  79-81 
Hairy  mole,  598 

Hamburger's  tuberculin  test  for  tuber- 
culosis, 701 
Hamilton   and    Cooke    on   gonococcus 

vaccine,  800 
Hand,  accoucheur,  in  tetany,  494 
Hand-I-hold  babe  mitt,  482 
Hard  ball  stools,  46 
Harelip,  168 

Harrison's  grooves  in  rachitis,  118 
Hay-fever,  301 
Hayem  on  red  cells,  394 
Head,  cold  in,  267 

lice,  574 
Headache,  470 

in  cerebrospinal  meningitis,  560 
Head-banging,  478 
Head-rolling,  478 
Hearing  in  new-born  infant,  42 
Heart    action    in    cerebrospinal    men- 
ingitis, 560,  562 


Heart   disease,    chronic   valvular,    389. 

See  also  Valvular  disease,  chronic, 

of  heart. 
congenital,  386 

cardiac  enlargement  in,  387 

classification  of  lesions,  387 

clubbed  fingers  in,  387,  388 

diagnosis,  387 

murmur  in,  388,  389 

pathology,  386 

polycythemia  in,  401 

prognosis,  386 

symptomatology,  386 
diseases  of,  368 

auscultation  in,  368 
diagnosis  in,  368 
inspection  in,  369 
palpation  in,  370 
percussion  in,  370 
thrill  in,  372 
disturbance  in  acute  infective  men- 
ingitis, 550 
enlargement   of,    in  congenital  heart 

disease,  387 
involvement  in  scarlet  fever,  treat- 
ment, 655 
murmurs,  cardiorespiratory,  373 
functional,  370,  372 

after  acute  illness,  374 

diagnosis,  differential,  373 

during  development,  374 

etiology,  373 

treatment,  374 
in  aortic  regurgitation,  372 
in  aortic  stenosis,  372 
in  congenital  heart  disease,  388 
in  mitral  regurgitation,  371 
in  mitral  stenosis,  371 
inorganic,  370 

location  of  lesions  by,  371     • 
no  n- valvular,  370 
organic,  370 
valvular,  370 
venous,  373 
rest  in  chronic  valvular  heart  disease, 

392 
sepsis  of,  in  new-born,  147 
sounds,  first,  368 
normal,  368 
second,  368 
stimulants  in  bronchopneumonia,  340 
in  chronic  valvular  disease,  392 
in  diphtheria,  636 


884 


INDEX 


Heart  stimulants  in  lobar  pneumonia, 
329 
in  typhoid  fever,  665 
tuberculosis  of,  363 
Heat,   artificial,  for  premature  infant, 
140 
as  therapeutic  agent,  784 
dry,  785 
local  application  of,  in  acute  diffuse 

nephritis,  447     , 
moist,  784 
prickl}^,  569 
Heating  of  nursery,  37 
Hecker  on  leukocytosis  in  measles,  400 
Height,  41 

Heiman  on  icterus  neonatorum,  144 
Hektoen  on  leukocj^osis  in  measles,  400 
Heliotherapj^    in    chronic    tuberculous 
peritonitis,  698 
in  pulmonary  tuberculosis,  366 
Heller  and  Levin  on  syphilis,  686 
Hematemesis,  182 

Hematoma  of  sternocleidomastoid,  752 
Hematuria,  436 
Hemicephalus,  501 
Hemiplegia,  514,  516 
Hemoglobin,  394 

percentage  of,  in  blood  in  new-born, 
394 
Hemoglobinuria,  436 

paroxysmal,  436 
Hemolysis,    prevention    of,    in    blood 

transfusion,  786 
Hemophilia,  411-413 
Hemorrhage  from  stomach,  182 
in  acute  hereditary  syphilis,  681 
in  typhoid  fever,  treatment,  666 
intestinal,  in  typhoid  fever,  660 
nasal,  treatment,  271 
Hemorrhagic  diseases  of  new-born,  157 
bacteria  as  factor,  158 
chemical  agents  as  etiologic  fac- 
tor, 159 
heredity  as  etiologic  factor,  159 
Kerley's  treatment,  161 
mechanical    means    as    etiologic 

factor,  159 
metabolic    changes    as    etiologic 

factor  in,  159 
serum  treatment,  160 
syphilis  as  etiologic  factor,  158 
treatment,  160 
Welch's  treatment.  180 


Henoch's  purpura,  409 
Hepatization,    gray,     in    lobar    pneu- 
monia, 321 

red,  in  lobar  pneumonia,  321 
Heredity  and  environment,  743 

as  cause  of  convulsions,  484 

as  factor  in  hemorrhagic  diseases  of 
new-born,  159 
in  nutrition  and  growth   of  new- 
born infant,  17 

effect  of,  on  posture,  809 

in  hysteria,  473 
Hereditary  ataxia,  548-550 

cerebellar  ataxia,  exercises  for,  829- 
841 

spinal   ataxia,  exercises  for,  829-841 

syphilis,  acute,  678.     See  also  Syphi- 
lis, acute  hereditary. 
tardy,     683.     See     also     Syphilis, 
tardy  hereditary. 
Hernia  at  umbilicus,  753 

congenital  umbilical,  754 
treatment,  754 

diaphragmatic,  757 

inguinal,  755 

of  umbiUcal  cord,  753 

ventral,  756 
Herter,  intestinal  infantilism  of,  231 
Herty  mask  in  eczema,  591 
Hess  bulb  in  pyloric  stenosis,  189 

on  feeding  in  pyloric  stenosis,  193 

on  icterus  neonatorum,  144 

on  pyloric  stenosis,  191 

on  starch  digestion,  68 
Heubner  on  calorimetric  principles  in 
infant  feeding,  66 

on  cerebrospinal  meningitis,  557 
Hiccup,  483 

Hip,  tuberculosis  of,  diagnosis,  758 
Hirsch  on  amaurotic  family  idiocy,  507 
Hirschfeld  on  rachitis,  117 
Hirschsprung's  disease,  230 

theory  of  pyloric  stenosis,  187 
Hirt  on  etiology  of  chorea,  519 
Hirth  on  cerebrospinal  meningitis,  557 
History  record,  132 
Hives,  570.     See  also  Urticaria. 
Hodgkin's  disease,  413 
Hoffmann  and  Schaudinn  on  Spirochseta 

pallida,  677 
Hoffmann  and  Werdnig  on  progressive 

amyotrophy,  526 
Hofmeier  on  icterus  neonatorum,  143 


INDEX 


885 


Hofmeister  on  icterus  neonatorum,  143 

Holb  on  tetany,  493 

Holberstein  on  icterus  neonatorum,  143 

Hollander  on  stammering,  526 

Holt  and  Brown  on  salvarsan  in  syphilis, 

684 
Holt    on    average    weight     of    house- 
clothing,  40 
of  new-born  infant,  39 

on  blood  findings  in  leukocytosis,  400 

on  capacity  of  stomach,  172 

on  deafness  in  scarlet  fever,  655 

on  duodenal  ulcer,  184 

on  enlargement  of  thymus  gland,  425 

on  eosinophilia  in  asthma,  399 

on  hydrocephalus,  510 

on  intussusception,  234 

on  leukocytosis  in  measles,  400 
in  scarlet  fever,  400 

on  pyloric  stenosis,  186 

on  siphon  drainage  in  empyema,  356 

on  splenomyelogenous  leukemia,  407 

on  temperature  elevation,  749 

on  tetanus  neonatorum,  156 

on  tuberculous  adenitis,  420 
Home  on  diphtheria,  626 
Hoobler  and  Howland  on  blood-pressure 

in  pneumonia,  402 
Hoobler  on  blood-pressure,  401 
Hook-worm,  250 

Hopping  in  congenital  ataxias,  839 
Horsley  on  cretinism,  727 
Hot  applications  in  acute  ileocolitis,  225 
in  colic,  216 

bath,  781 
Howitz  on  cretinism,  728 
Howland  and  Hoobler  on  blood-pressure 

in  pneumonia,  402 
Howland  and  Harriot  on  spasmophilia, 

489 
Howland  on  blood-pressure,  401 

on  hypodermoclysis,  796 
Human  milk,  31.     See  also  Breast-milk. 

serum  in  acute  poliomyelitis,  541 
Hutchinson  teeth  in  tardy  hereditary 

syphilis,  688 
Hutinel  on  blood-pressure,  401 
in  contagious  diseases,  402 
Hydrencephalocele,  499 
Hydrocele,  463 

common  vaginal,  464 

congenital,  463 

funicular,  463 


Hydrocele,  infantile,  463 
inguinal  hernia  and,  differentiation, 

755 
of  cord,  463 

encysted,  464 
of  tunica  vaginalis,  464 
treatment,  464 
varieties,  463 
Hydrocephalus,  509 
acquired,  509 
congenital,  510 
diagnosis,  512 
duration,  511 

encephalocele  and,  differentiation,  143 
external,  509 
chronic,  510 
congenital,  510 
internal,  509 
acute,  510 
chronic,  510 
prognosis,  512 

rachitis  and,  differentiation,  120 
symptoms,  510 
treatment,  512 
Hydro  myelocele,  501 
Hydronephrosis,  439 
Hydrotherapy     in    lobar     pneumonia, 

329 
Hygiene    in    pulmonary    tuberculosis, 
365 
in  rachitis,  121 
Hyperemia     treatment     of     persistent 

simple  adenitis,  418 
Hypernephroma  of  kidney,  439 
Hyperplastic  chondrodystrophia,  725 
Hyperpyrexia,  745 

Hypertrophy  of  turbinated  bones,   as 
cause  of  chronic  rhinitis,  269 
pseudomuscular,  530 
Hypodermic  feeding,  82 

medication     in     bronchopneumonia, 
340 
in  convulsions,  486 
stimulation  in  lobar  pneumonia,  331 
Hypodermoclysis,  796 
Hypoplastic  chondrodystrophia,  725 
Hypospadias,  464 
Hypostatic  pneumonia,  345 
Hysteria,  472,  498 
convulsive  cases,  474 
diagnosis,  475 
drugs  in,  477 
duration,  475 


886 


INDEX 


Hysteria,  etiologj^,  473 

globus  hystericus  in,  474 

heredity  in,  473 

imitation  in,  473 

mental  activity  in,  476 

motor  type,  474 

physical  activity  in,  476 

sensory  type,  475 

symptoms,  474 

treatment,  475 

during  seizure,  477 
Hysteric  mania,  498 

Ibrahim  on  pyloric  stenosis,  186 
Ice-bag  in  acute  endocarditis,  381 
Ichthyol  in  erysipelas,  583 
Icterus,  265 
catarrhal,  265 
neonatorum,  143-145 
obstructive,  265 
Idiocy,  503 

amaurotic  family,  507-509 
cretinoid,  727.     See  also  Cretinism. 
MongoHan,  503-505 
Idiopathic  dUatation  of  colon,  230 
Idiosyncrasy  to  cow's  milk,  in  malnu- 
trition, 98 
to  foods,  79 
Ileocolitis,  acute,  220 

associated  lesions,  222 
bacteriology,  221 
climatic  influence,  226 
colon  irrigation  in,  225 
diet  in  convalescence,  226 
drugs  in,  224 
duration,  223 

obstinate    constipation    in,    treat- 
ment, 227 
pathology,  221 
symptoms,  222 
treatment,  223 
chronic,  227 

colon  irrigation  in,  229 
constipation  in,  treatment,  229 
diet  in,  228 
symptoms,  228 
treatment,  228,  229 
pseudomembranous,  222 
severe,  222 
simple  catarrhal,  221 
ulcerative,  222 
Ileus,  paralytic,  245 
treatment,  202 


Illness,  acute,  attendants,  134 
bowel  feedings,  136 

function  in,  136 
care  of,  130 

essentials  in,  133 
clothing,  134 

essentials  in  care,  cold  air,  134 
diet,  135 

drinking  of  water,  134 
drugs,  136 

examination  of  urine,  135 
keeping  in  bed,  133 
needless  interference,  135 
room  temperature,  134 
sick-room,  134,  137 
sponging,  134 
stimulation,  137 
ventilation,  134 
window-board,  138 
nephritis  in,  135 
pyrexia  in,  treatment,  136 
diet  during,  109 

reduction  in  food  strength,  109 
Imbecility,  503 
Imitation  in  hysteria,  473 
Immerman  on  hemophilia,  412 
Immunity,  797 

in  acute  poliomyelitis,  537 
in  diphtheria,  634 
in  typhoid,  duration,  659 
Imperative  concepts,  498 
Imperial    granum   water,   formula  for, 

70 
Impetigo  contagiosa,  579 
Incision,   exploratory,    in  appendicitis, 

254 
Incontinence  of  feces,  232 

of  urine,  432-434 
Incubators,   baby,  defective  air  supply 

in,  140 
Index,  opsonic,  798 

phagocytic,  798 
Indigestion,  gastric,  acute,  174 
chronic,  175 
intestinal  acute,  204 
persistent,  205 

in  older  children,  treatment,  207 
Individual  child,  treatment  and  care  of, 

139 
Infant,   new-born,   17.     See  also  New- 
horn  infant. 
Infantile  atrophy,  86.     See  also  Maras- 


INDEX 


887 


Infantile    convulsions,   483.      See  also 

Convulsions. 
hydrocele,  463 
myopathy     of     facioscapulohumeral 

type,  530 
myxedema,  727.     See  also  Cretinism. 
paralysis,  535.     See  also  Poliomyelitis, 

acute. 
scurvy,  112 
Infantilism,  intestinal,  of  Herter,  231 

symptomatic,  733 
Infectious  diseases,  cereal  gruels  in,  67 
Influenza,  670 

acute  rhinitis  and,  differentiation,  268 

adenitis  in,  675 

age  incidence,  671 

bacteriology,  670 

bronchitis  in,  674 

bronchopneumonia  in,  674 

change  of  climate  in,  677 

climate  in,  773 

colitis,  674 

complications,  674 

cough  in,  672 

treatment,  676 
diagnosis,  675 
drugs  in,  677 
duration,  675 
etiology,  670 
external  treatment,  677 
fatal  cases,  674 
gastritis,  674 

gastro-intestinal  manifestations,  673 
incubation  period,  672 
kidneys  in,  675 
leukocytosis  in,  397 
mode  of  entrance,  671 
nephritis  in,  675 
otitis  in,  674 
pathology,  671 
persistent  fever  in,  675 
prognosis,  675 
quarantine  in,  676 
sequelae,  675 
source  of  infection,  671 
symptoms,  672 
temperature  in,  674 
treatment,  676 
Ingelev  on  scurv^y.  111 
Inguinal  adenitis,  417 

glands,     enlarged,     inguinal     hernia 

and,  differentiation,  756 
hernia,  755 


Inhalations,  steam,  in  bronchitis,  312 
in  bronchopneumonia,  338 
in  spasmodic  croup,  290 
stimulant,  in  acute  spasmodic  bron- 
chitis, 319 
Inorganic  heart  murmurs,  370 
Insanity,  497 
choreic,  518 
Inspection,  diagnosis  by,  131 
during  sleep,  132 
in  acute  endocarditis,  379 
in  diseases  of  heart,  369 
of  chest,  302 
of  lungs,  302 
Interstitial   pneumonia,  342.     See  also 

Pneumonia,  interstitial. 
Intertrigo,  prevention  of,  568 
Intestinal  cysts,  246 

diseases  of  summer,  etiologic  factors, 
216 
importance  of  prompt  treatment 

217 
prevention,  216 

dispensary  rules  for,  217 
how  to  secure  good  milk,  218 
necessity    of    education    for, 

218 
New  York  City  experiments, 
217 
diverticula,  congenital,  246 
hemorrhage  in  typhoid  fever,  660 
indigestion,  acute,  204 
persistent,  205 

in  older  children,  206 
infantilism  of  Herter,  231 
infection   as    cause    of    elevation   of 
temperature,  749 
with  defective  bowel  action,  treat- 
ment, 202 
intussusception,  233-236 
obstruction,  244 
parasites,  247 

blood  in  infections  by,  247 
as  cause  of  convulsions,  484 
tract,  mechanical  agencies  in,  diges- 
tive disturbances  from, 
208 
constipation     in,      treat- 
ment, 213 
diarrhea  in,  treatment,  214 
massage  in,  213 
medication  in,  213 
symptoms,  208 


888 


INDEX 


Intestines,  diseases  of,  172 
invagination  of,  233-236 
sepsis  of,  in  new-born,  147 
tuberculosis  of,  364 
Intoxication,  acute  enteric,  201-203 
gastro-enteric,  194.     See  also  Gastro- 
enteric intoxication. 
Intubation  in  diphtheria,  638-642 
Intussusception,  233-236 

peritonitis,  and,  differentiation,  257 
appendicitis  and,  differentiation,  254 
Invagination  of  intestines,  233-236 
Inward  convulsions,  485 
lodid  of  potash,  782 
Ipecac,  782 

Iphophon  on  cretinism,  728 
Irrigation,  colon,  793 

in  acute  enteric  intoxication,  203 

ileocolitis,  225 
in  chronic  ileocolitis,  229 
technic,  794 
of  throat,  278 

in  peritonsillar  abscess,  284 
indications,  278 
technic,  278 
Iron,  tincture  of  muriate,  783 
Ischiorectal  abscess,  262 
Italian  leprosy,   738 
Itch,  572 
Ivy  poiGoning,  571 

Jackson  on  treatment  of  nsevus,  599 
Jacobi   and  WoUstein  on  tuberculosis, 

693 
Jacobi  on  cerebrospinal  meningitis,  557 
Janeway  on  causes  of  hypotension,  402 

on  chronic  valvular  disease  of  heart, 
389 
Japha  on  leukocytosis,  396 
Jaundice,  143-145 

catarrhal,  265 

obstructive,  265 
Javal  on  salt-free  diet  in  acute  nephritis, 

446 
Jaw,  drop,  in  adenoids,  295 
Jobling  and   Flexner  on  antimeningo- 
coccus  serum,  800 
on  cerebrospinal  meningitis,  557 
Jochmann  and   Krause  on  whooping- 
cough,  614 
Joint  diseases,  diagnosis,  757 

tuberculosis,  diagnosis,  758 
Joints,  sepsis  of,  in  new-born,  146 


Jumping  in  congenital  ataxias,  839 
Junket,  formula  for,  71 
Jurgensen  on  scarlet  fever,  643 
Juvenile    type    of    progressive    amyo- 
trophy, Erb's,  530 

Karo  on  pyloric  stenosis,  187 
Karznicki  on  transitional  cells,  395 
Kassowitz's  theory  of  tetany,  492 
Keller   and    Czerny   on  excessive   am- 
monia excretion,  100 
Kenyon    on   siphon    drainage    in    em- 
pyema, 356 
Kernig's  sign  in  cerebrospinal  menin- 
gitis, 561 
in  tuberculous  meningitis,  555 
Key-note  position  in  scoliosis,  824 
Kidney,  cysts  of,  441 
diseases  of,  438 
in  influenza,  675 
new-growths  of,  438 
of  scarlet  fever,  442 
tuberculosis  of,  364,  438 
tumors  of,  439 
Kindt  on  hernia  of  umbilical  cord,  753 
King  on  blood  transfusion,  786 
Kingdon  on  amaurotic  family  idiocy, 

509 
King's  cough,  614 
Kinkcough,  614 

Kirchoff  on  heredity  in  insanity,  497 
Kitasato  on  tetanus  bacillus,  156 
Klebs-Loffler  bacillus,  626 

infection  by,  as  cause  of  chronic 

rhinitis,  269 
persistent  nasal  infection  with,  637 
Kleptomania,  498 
Knee-crutch  to  prevent  masturbation, 

480 
Knoepfelmacher  on  acute  poliomyeUtis, 
537 
on  hemorrhagic  diseases  of  new-born, 
159 
Koch  on  hemophilia,  412 
Kocher  on  cretinism,  728 
Kolmer   on  blood    findings   in   scarlet 
fever,  401 
on  scarlet  fever,  643 
Kolossowa  on  blood-pressure,  401 
Koplik  and  Unger  on  Schick  test,  028 
Koplik  on  age  in  cerebrospinal  menin- 
gitis, 559 
on  blood  in  anemia,  403 


INDEX 


889 


Koplik  on  epilepsy,  532 

on  localization  of  lobar  pneumonia, 

322 
on  leukocytosis  in  pneumonia,  397 
on  Still's  disease,  724 
spots  in  measles,  621 

Koplik's   method   in   asphyxia    neona- 
torum, 150 

Korsakoff  on  bacteriology  of  glandular 
fever,  419 

Krause    and    Jochmann  on  whooping- 
cough,  614 

Kretschmar  on  scarlet  fever,  643 

Krumwiede  and  Park  on  bovine  tuber- 
culosis, 691 

Kyphosis,  exercises  for,  817 

Laborde's  method  of  artificial  respira- 
tion in  asphyxia  neonatorum,  150 

Lactalbumin  of  cow's  milk,  49 

Lactic  acid  milk,  65 

Lactose  of  cow's  milk,  49 

Ladder  exercises  in  congenital  ataxias, 
837 

La  Fetra  on  acute  spasmodic  bronchitis, 
319 
on  blood    findings   in  poliomyelitis, 
398 

Lamar    and    Meltzer    on    Diplococcus 
pneumoniae,  321 

Lamb  on  calorimetric  principles  in  in- 
fant feeding,  66 

Lambert   on   hemorrhagic    diseases    of 
new-born,  160 

Landau  on  hemorrhagic  diseases  of  new- 
born, 159 

Landouzy-Dejerine  type  of  progressive 
amyotrophy,  530 

Landsteiner  and  Papper  on  acute  polio- 
myelitis, 536 

Landsteiner  on  acute  poliomyelitis,  537 
on  scarlet  fever,  643 

Langer  on  sclerema  neonatorum,  145 

Langhans  on  cretinism,  729 

Langstein  on  diabetes  mellitus,  735 

Laryngeal  diphtheria,  636 
obstruction,  292 
stridor,  congenital,  491 

in  laryngismus  stridulus,  487 

Laryngismus  stridulus,  487-489 

Laryngitis,   acute  catarrhal,   287.     See 
also  Spasmodic  croup. 
traumatic,  291 


Larynx,  foreign  bodies  in,  292 
tuberculosis  of,  364 

Lavage,  788 

in  marasmus,  90 

in  vomiting  in  infants,  185 

indications,  789 

intestinal,  in  typhoid  fever,  666 

technic,  788 

Laxatives  in  scarlet  fever,  652 

Leclef  on  phagocytosis,  797 

Leg-rubbing,  480 

Leiner  and  v.  Weisner  on  acute  polio- 
myelitis, 537 

Leishmania  infantum,  263 

Lenz  on  precocious  maturity,  457 

Leprosy,  Italian,  738 

Leukemia,  407 

Leukocytes   found   in  pathologic    con- 
ditions, 395 

Leukocytosis,  396 
absolute,  396 
pathologic,  396 
physiologic,  396 
relative,  396 

Levaditi   and    Netter   on   acute   polio- 
myelitis, 537,  540 
on  acute  poliomyelitis,  537 
on  scarlet  fever,  643 

Levin  and  Heller  on  syphilis,  686 

LeWald  and  Smith  on  position  after 
feeding,  94 

Lewis  and  Flexner  on  acute  poliomye- 
litis, 537 

Lice,  head,  574 

Limbeck  on   leukocytosis    in  tubercu- 
losis, 398 

Lind  and  Van  Cott  on  trichiniasis,  251 

Lindemann  method  of  blood  transfusion 
in  secondary  anemia,  404 
on  blood  transfusion,  786 

Lingual  tonsils,  279 

Lips,  fissures  of,  167 

Liver,  abscess  of,  264 

atrophy  of,  acute  yellow,  264 

cirrhosis  of,  264 

diseases  of,  263 

in  acute  hereditary  syphilis,  680 

in  leukemia,  408 

in  tardy  hereditary  sypliilis,  688 

tuberculosis  of,  363 

Lobar  pneumonia,  320.     See  also  Pneu- 
monia, lobar. 

Long  sigmoid,  208 


890 


INDEX 


Loss  of  appetite,  habitual,  79-81 
Lowenburg  on  spasmophilia,  490 
Lower  on  blood  transfusion,  786 
Lucas    and    Osgood    on    acute    poUo- 
myeUtis,  537 
and  Prizner  on  measles,  620 
Lucretius  on  epilepsy,  531 
Luetin  test  in  syphilis,  706 
Lumbar    puncture    in    acute    infective 
meningitis,  552 
in  meningismus,  566 
in  tuberculous  meningitis,  555 
method,  566 
needle  for,  566 
position  of  patient,  566 
site  for,  566 
uses,  567 
Lungs,    acute   pneumococcus   infection 
of,  316 
auscultation  of,  304 
consolidation  of,  in  lobar  pneumonia, 

326 
defective  expansion  of,  303 
diseases  of,  302 
dulness  of,  304 

tympanitic,  304 
examination  of,  302 
inspection  of,  302 
palpation  of,  303 
percussion  of,  303 
resonance  of,  303 
tympanitic,  304 
sepsis  of,  in  new-born,  147 
Lymphadenoma,  413 
Lymphatic  glands,  diseases  of,  415 

enlargement  of,  in  German  measles, 
625 
leukemia,  407 
Lymphatism,     424.     See     also     Status 

lymphaticus. 
Lymph-glands,  cervical,  tuberculosis  of, 

364 
Lymph-nodes,  cervical,  tuberculosis  of, 
420 
in  Hodgkin's  disease,  414 
in  leukemia,  408 

in  tardy  hereditary  syphilis,  686,  688 
Lymphocytes,  394 
Lymphomata  in  leukemia,  408 
Lysins,  797 

Mackenzie  on  cretinism,  728 
MacLeod  on  diabetes  mellitus,  735 


Maid,  nursery,  38 
Malaria,  666 
diagnosis,  668 

differential,  669 
empyema  and,  differentiation,  355 
mosquito  transmission,  667 
pathology,  667 
physical  examination,  668 
Plasmodia  of,  species,  667 
prophylaxis,  669 
quinin  in,  669 
recurrence,  670 
relapse  in,  668 
symptoms,  668 
transmission,  667 
treatment,  669 
yerberzine  in,  669 
Male  genitals,  diseases  of,  459 

gonorrhea  in,  464 
Malformation  of  brain,  499 
of  esophagus,  171 
of  individual  lobes  of  brain,  501 
of  spinal  cord,  499 
Mallory  on  pathology  of  typhoid,  658 

on  scarlet  fever,  644 
Malnutrition,  92 

as  cause  of  chronic  rhinitis,  270 
climate  in,  774 
diagnosis,  93 
diet  in,  93 
etiology,  92 
gavage  in,  792 

idiosyncrasy  to  cow's  milk  in,  98 
in  older  children,  100 
symptoms,  92 
tardy,  100 

of  syphilitic  origin,  689 
treatment,  690,  691 
treatment,  93 
Malted  foods  in  constipation  in  nurs- 
lings, 239 
Malt-soup  feeding,  64 
in  marasmus,  94 
Mammary  abscess  in  new-born,  155 
Mania,  499 

hysteric,  498 
Mann  and  Danielson  on  cerebrospinal 

meningitis,  557 
Marasmus,  86 
age  of  occurrence,  86 
cow's  milk  in,  91 
etiology,  86 
feeding  in,  90 


INDEX 


891 


Marasmus,  history,  86 
infection  as  cause,  87 
lavage  in,  90 
pathology,  86 

pyloric  obstruction  as  cause,  87 
sweetened  condensed  milk  in,  91 
treatment,  87 
outdoor,  89 

where  wet-nurse  is  impossible,  90 
wet-nursing  in,  88 
Market  milk,  50 
Marriot  and  Howland  on  spasmophilia, 

489 
Martin  on  diphtheria,  626 
Mask,  Herty,  in  eczema,  590 
Mason  on  localization  of  lobar  pneu- 
monia, 322 
on  marginal  pneumonia,  326 
on  starch  digestion  in  infant,  68 
Massage  in  acute  poliomyelitis,  542 
in  anterior  poliomyelitis,  843 
in  constipation  in  nurslings,  239 
in  mechanical  intestinal  disturbances, 
213 
Mast  cells,  395 
Mastitis,  acute,  36 
in  new-born,  155 
in  young  girls,  422 
suppurative,  36 
Mastoiditis,  606 
Masturbation,  479 
brace  to  prevent,  481 
Hand-I-hold  mitt  to  prevent,  482 
knee-crutch  to  prevent,  480 
prophylaxis,  480 
treatment,  480 
Maternal  nursing,  21 

air  and  exercise  for  mother  in,  25 
care  of  nipples  in,  31 
conditions  forbidding,  29 
constipation   in   mother  in,   treat- 
ment, 25 
diet  in,  24 
frequency,  26 
management    of    abnormal    milk 

conditions,  28 
mixed  feeding,  29 
regularity  in,  25 
signs  of  insufficient,  28 
of  successful,  26 
of  unsuccessful,  26 
temporary  discontinuance  of,  30 
water  for  mother  in,  26 


Mathews  on  operation  for  removal   of 

tonsils  and  adenoids,  298 
Maturity,  precocious,  456 
May  on  deafness  in  scarlet  fever,  655 
Mc Galium   and   Voegtlin   on    spasmo- 
philia, 489 
on  tetany,  494 
McKenzie's  exercise  in  emphysema,  828 
McKernon    on    treatment     of     acute 

otitis,  605 
Measles,  619 
age  incidence,  620 
baths  in,  623 

bronchopneumonia  in,  621 
care  of  bowels  in,  623 
complications,  621 
cough  in,  620 

treatment,  623 
diagnosis,  621 
diet  in,  622 
ears  in,  care  of,  623 
etiology,  620 
eyes  in,  620 

care  of,  622,  623 
feeding  in,  622 
fresh  air  in,  624 
German,  624 
incubation  period,  620 
KopUk  spots  in,  621 
leukocytosis  in,  400 
nephritis  in,  622 
nervous  manifestations,  620 
otitis  in,  621 
prognosis,  622 
quarantine  in,  624 
rash  in,  621 

delayed,  623 
recurrence,  622 
second  attack,  622 
symptoms,  620 
temperature  in,  621 
transmission,  619 
treatment,  622 
vapor,  624 
Mechanical  agencies  in  intestinal  tract, 
digestive    disturbances 
from,  208 
constipation  in,  treatment 

213 
•  diarrhea  in,  treatment,214 
massage  in,  213 
medication  in,  213 
sj'inptoms,  208 


892 


INDEX 


Mediastinum,  emphysema  of,  347 

Melancholia,  498 

Meloena  neonatorum,  158 

Meltzer    and    Lamas    on    Diplococcus 

pneumoniae,  321 
Membranous  non-diphtheric  angina  in 
diphtheria,  647 
proctitis,  261 
Memory,    beginning    of,    in    new-born 

infants,"  43 
Mendel  and  Rose  on  creatin  excretion 

in  starvation,  663 
Meniere's   disease  in  tardy  hereditary 

syphilis,  686 
Meningismus,  565 
diagnosis,  565 

differential,  565 
lumbar  puncture  in,  566 
symptoms,  565 
treatment,  566 
Meningitis,  acute  infective,  550-552 
cerebrospinal,    557.     See    also    Cere- 

brospinal  meningitis. 
in  lobar  pneumonia,  325 
leukocytosis  in,  398 
serous,  565 
tuberculous,  553 
age  incidence,  553 
diagnosis,  555 
differential,  556 
duration,  556 
Kernig's  sign  in,  555 
lumbar  puncture  in,  555  . 
pathology,  553 
prognosis,  556 
symptoms,  553 
treatment,  557 
Meningocele,  499 

of  spinal  cord,  501 
Meningococcus  intracellularis,  557 
normal  strain,  558 
parameningococcus  strain,  558 
vaccine,  800 
Mensi  on  sclerema  neonatorum,  145 
Menstruation,  precocious,  456 
Mental  apathy  in  cerebrospinal  menin- 
gitis, 560 
deficiency,  503 

institutional  treatment,  506 
treatment,  505 
unclassified  cases,  503 
development  of  new-born  infant,  42 
impairment  in  cerebral  paralysis,  517 


Mentality  in  cerebral  paralysis,  515 
Mercury  bichlorid,  782 

in  acute  hereditary  syphilis,  682-684 
Mesenteric  gland,  tuberculosis  of,  364, 

694 
Metabolic  changes  as  etiologic  factor  in 
hemorrhagic    diseases    of    new-born, 
159 
Metchinkoff  on  phagocytosis,  797 
Meyer  and  Finkelstein's  Eiweiss  milk, 
65 
on  adenoids,  293 
Meyers  on  sclerema  neonatorum,  145 
Microcephalus,  500 
Micrococcus  lanceolatus,  321 
Micromelia,  725 
Middle-ear     disease,     601.     See     also 

Otitis,  acute. 
Miliaria,  569 

Milk,  breast-,  31.     See  also  Breast-milk. 
certified,  50 

requirements  of  New  York  County 
Medical  Society  Milk  Commis- 
sion for  production,  51 
rules  for  producer,  51-54 
condensed,  in  gastro-enteric  intoxica- 
tion, 200 
in  malnutrition,  95 
cow's,  49 

adaptation  of,  54,  62 

by  alkalis  and  antacids,  63 

by  cereal  gruels,  64 

by  malt-soup  extract,  64 

feeding,  64 
by  sodium  citrate,  63 
by  whey-feeding,  64 
symptomatic,  62 
casein  of,  49 
examination,  54 
fat  of,  modification,  56 
fresh,  added  to  proprietary  foods, 

73 
harmful  bacteria  in,  50 
idiosyncrasy    to,    in   malnutrition, 

99 
in  malnutrition,  94 
in  marasmus,  91 
lactalbumin  of,  49 
lactose  of,  49 
legal  standards  for,  50 
market,  50 

mixed  dairy,  analysis,  55 
mixtures  with  cream,  57,  58 


INDEX 


893 


Milk,  cow's,  modified,  54 
aim  of,  55 
by  cream  and  milk  mixtures,  56- 

58 
by  dilution,  55 
by  skimming,  57 
by  top-milk  methods,  59 
fat  of,  56 

formulas  for,  58-61 
proteid  of,  55 
sugar  of,  56 
plain,  in  malnutrition,  98 
proteids  of,  49 

modification,  55 
quality  variable,  61 
raw,  advantages  of,  if  pure,  76 
skimmed,  mixtures  of,  57 
solids  of,  49 
stools  from,  46 
sugar  of,  modification,  56 
crust,  595 

diet  in  scarlet  fever,  651 
Eiweiss,  65 

in  gastro-enteric  intoxication,  201 
evaporated,  in  gastro-enteric  intoxi- 
cation, 200 
in  malnutrition,  96 
for  traveling,  69 
frozen,  78 

general  properties  of,  104 
good,  how  to  secure,  218 
human,  31.     See  also  Breast-7nilk. 
in  typhoid  fever,  663 
infection  of,  tuberculosis  from,  693 
lactic  acid,  65 
pasteurization  of,  74 

advantage  and  value  of,  75 
effect  on  assimilation,  77 
peptonized,  68 
completely,  69 
for  gavage,  68 
for  nutrient  enema,  68 
partially,  69 
processes,  69 
polluted,    as    cause    of    septic    sore 

throat,  286 
protein,  65 

in  gastro-enteric  intoxication,  201 
safe,  how  to  obtain  in  summer,  764 
selection  of,  in  summer,  763 
skimmed,  in  gastro-enteric  intoxica- 
tion, 198 
sterilization  of,  74 


Milk,  substitutes   in   gastro-enteric  in- 
toxication, 196 

sweetened  condensed,  in  marasmus, 
91 

withdrawal  of,  in  summer,  763 
Miller  and  Wilcox  on  pyloric  stenosis, 

187 
Miller  on  pyloric  stenosis,  187 

on  salt-free  diet  in  acute  nephritis,  446 
Miner's  anemia,  247 
Minkowski  on  diabetes  mellitus,  735 
Mirrors,  double,  during  exercise,  772 
Mitral  regurgitation,  heart  murmur  in, 
371 
treatment,  391 

stenosis,  heart  murmur  in,  371 
treatment,  391 
Mitt,  Hand-I-hold,  482 
Modified    milk,    54.     See    also    Milk, 

cow's,  modified. 
Moist  heat,  784 

rales,  307 
Mole,  hairy,  598 
MoUer  on  scurvy.  111 
Moller-Barlow's  disease,  112.     See  also 

Scurvy. 
Mongolian  idiocy,  503-505 

rachitis  and,  differentiation,  120 
Mongolianism,  503-505 
Mononuclears,  large,  395 
Monti  on  rachitis,  117 
Morbid  fears,  498 
Morbus  comitialis,  531 

Herculeus,  531 

sacer,  531 
Moro  on  leukocytosis,  396 

on  starch  digestion,  68 

tuberculin   inunction   test   in   tuber- 
culosis, 702 
Morse  and   Floyd  on  bacteriology  of 

chorea,  519 
Morse    on    acute    retropharyngeal    ab- 
scess, 276 

on  leukocytosis  in  diphtheria,  400 

on  precocious  menstruation,  456 
Mosher's  kindergarten  chair,  SOS 
Mosquito  in  etiology  of  malaria,  667 
Mother,  bi'east  of,  34 

nvu'sing,  21.     See  also  Maternal  nurs- 
ing. 
Motility  of  stomach,  173 
Mouth,  diseases  of,  162 

toilet  in  typhoid  fever,  661 


894 


INDEX 


Mouth,     ulcerations     and     fissures    at 

angle,  168 
Mouth-breathing  in  adenoids,  294 
Mouth-washing  in  stomatitis,  165 
Mucous  coHtis,  229 

membrane,  respiratory,  in  tardy  her- 
editary sjTJhilis,  686 
patches  in  acute  hereditary  syphilis, 

681 
rales,  307 
Mucus  in  stools,  47 
Muenier  and  Frohlich  on  leukocytosis 

in  whooping-cough,  400 
Miiller  on  acute  poliomj^elitis,  539 

on  blood-findings  in  poliomyelitis,  398 
Multiple  neuritis,  542.     See  also  Neu- 
ritis, multiple. 
Mumps,  611-613 
Muriate  of  iron,  tincture,  783 
Murkel  on  weight  of  thymus,  423 
Murmurs,  heart,  370.     See  also  Heart 

murmurs. 
Murmur,  regurgitant,  370 

stenotic,  370 
Murray  on  cretinism,  727 
Muscle  irritability  in  tetany,  494 
rigidity  in  cerebrospinal  meningitis, 
560 
localized  in  appendicitis,  253 
Muscular  atrophies,  progressive,  526 
atrophy,  progressive  spinal,  Charcot- 
Marie-Tooth  type,  527 
claw-hand  in,  527 
course,  528 
.    Duchenne-Aran  type,  527 
etiology,  526 
hand  type,  527 
leg  type,  527 
peroneal  type,  527 
prognosis,  528 
spastic  type,  527 
pathology,  526 
symptoms,  527 
treatment,  528 
primary  dystrophy,  530 
Musical  rales,  307 
Mustard  bath,  780 
Mutton  broth,  formula  for,  70 
Mycotic  stomatitis,  162 
Myelocystocele,  501 
Myelocytes,  395 

eosinophilic,  395 
Myelomeningocele,  501 


Myers  on  micturition  in  new-born,  429 

on  temperature,  744 
Myocarditis,  383-385 

acute  parenchymatous,  383 
suppurative,  383 

chronic  interstitial,  384 

in  lobar  pneumonia,  325 

in  scarlet  fever,  648 
Myopathic  face,  531 
Myopathies,  526 

Myopathy,    infantile,    of  facioscapulo- 
humeral type,  530 
Myxedema,    infantile,    727.     See    also 

Cretinism. 

N^vus,  598 
fiammeus,  598 
linearis,  598 
lipomatodes,  598 
pilosus,  598 
pilus,  598 
vascular,  598 
verrucosus,  598 
Nails  in  acute  hereditary  syphilis,  681 
Nap,  midday,  for  delicate  children,  128 
Narcosis,  gavage  in,  792 
Nasal  catarrh,  269 
diphtheria,  637 
chronic,  637 
hemorrhage,  271 
infection,     persistent     with     Klebs- 

Loffler  bacillus,  637 
mucous  membrane  in  transmission  of 
acute  poliomyelitis,  537 
Naunyn's  exercise  for  empyema,  825 
Nauseating  drugs,  781 
Necrobiosis  in  storrtatitis,  164 
Needle  for  lumbar  puncture,  566 
Neisser  on  Wassermann  test  for  syphilis, 

704 
Neosalvarsan  in  acute  hereditary  syph- 
ilis, 684,  685 
Nephritis,  acute  diffuse,  441 
bath  in,  446 
bowels  in,  446 
colon  flushing  in,  447 
convalescence  in,  449 
convulsions  in,  444 
diagnosis,  444 
diet  in,  445 
duration,  444 
etiology,  441 
examination  of  urine,  444 


INDEX 


895 


Nephritis,  acute  diffuse,  fever  in,  443 
fulminating  cases,  444 
local  application  of  heat  in,  447 
pathology,  442 
prognosis,  444 
salt  free  diet  in,  446 
symptoms,  443 
time  of  development,  443 
toxic  agents  in  etiology,  441 
treatment,  445 

of  severe  cases,  446 
urea  excretion  in,  448 
uremia  in,  444 

treatment,  448 
urine  in,  443 
interstitial,  442 
chronic  dii^fuse,  449 

interstitial,  452 
climate  in,  774 
in  acute  illness,  135 
in  influenza,  675 
in  measles,  622 
in  scarlet  fever,  648 
treatment,  655 
Nervous  cough,  272 

disorders,  470 
Netter  and    Levaditi  on  acute   polio- 
myelitis, 537,  540 
Nettle-rash,    570.     See  also    Urticaria. 
Nettleship  on  hemophilia,  411 
Neuralgia,  intercostal,  counterirritants 

in,  776 
Neurasthenia,  498 
Neuritis,  multiple,  542 
after  diphtheria,  542 

treatment,  545 
convalescence  in,  545 
diagnosis,  544 

diphtheria  after,  gavage  in,  546 
distribution  of  lesion,  543 
drugs  in,  544 
etiology,  542 
pathology,  543 
prognosis,  544 
sensory  effects,  543 
symptoms,  543 
treatment,  544 
Neurotic  eczema,  593 
Neutropliiles,   polymorphonuclear,   395 
Nevus,  598.     See  also  Ncevus. 
New  York  City  experiments  in  preven- 
tion   of    intestinal    diseases    of 
summer,  217 


New    York    County    Medical    Society, 

Milk  Commission  of,  51 
New-born  infant,  17 

baskets  for  early  exercises,  44 

bathing,  20 

beginning  of  feeling  in,  43 

beginning  of  memory  in,  43 

blood  in,  394 

congenitally  weak,  140 

constipation  in,  238 

crying  of,  44 

cutaneous  sensation  in,  42 

diseases  of,  140 

feeding,  18 

fresh  air  for,  19 

hearing  in,  42 

jaundice  in,  143-145 

mammary  abscess  in,  155 

mastitis  in,  155 

mental  development,  42 

necessity   of   method   in    manage- 
ment of,  138 

nutrition  and  growth,  17 

environment  as  factor,  17 

heredity  as  factor,  17 

work  and  stress  as  factors,  20 

organic  sensation  in,  42 

physical  development,  42 

powder  for,  569 

premature,     140.     See    also     Pre- 
mature infant. 

selection  and  preparation  of  food, 
19 

sepsis  in,  146.     See  also  Sepsis  in 
new-born. 

sight  in,  42 

sleep  required,  45 

smell  in,  42 

stools  of,  46.     See  also  Stools. 

taste  in,  42 

tetanus  in,  156 

thirst-hunger  in,  42 

umbilical  granuloma  in,  154 

umbilical  polyp  in,  154 

vomiting  in,  management,  185 
lavage  in,  185 

weighing,  39 

weight,  38 
hemorrhagic  diseases  of,  157 
New-growths  of  kidney,  438 
NichoUs  and   Adami  on  pathology  of 
typhoid,  658 

on  rachitis,  118 


896 


INDEX 


Nicolaier  on  pellagra,  740 

on  tetanus  bacillus,  156 
NicoU  and  Bovaird  on  weight  of  thy- 
mus, 423 
Nicoll    on    blood    findings    in    scarlet 
fever,  401 

on  scarlet  fever,  643 
Nicolle  and  Pianese  on  splenomegaly, 

263 
Night  feedings,  61 
Night-terrors,  471 
Nihilism,  therapeutic,  771 
Nipples,  47 

care  of,  in  maternal  nursing,  31 

cracked,  34 

depressed,  35 

fissured,  34 
Nipple-shield,  31 
Nitroglycerin  in  bronchopneumonia,  340 

in  lobar  pneumonia,  330 
Nitrous  oxid  gas  as  anesthetic,  751 
Noguchi  and  Flexner  on  case  of  anterior 

poliomyelitis,  535 
Noguchi  butyric-acid  test  for  syphilis, 
705 

on  complement-fixation  test  in  syphi- 
lis, 705 

on  Spirochseta  pallida,  677 

luetin  test  in  syphilis,  706 
Noma,  166 

Northrup  on  sclerema  neonatorum,  145 
Nose,  diseases  of,  267 

saddle,  in  tardy  hereditary  syphilis, 
688 
Nursery,  36 

airing  of,  37 

floor  of,  36 

for  delicate  children,  127 

furniture  of,  37 

heating  of,  37 

maid,  38 

ventilation  of,  37 
Nursing-bottle,  47 
Nursing  in  scarlet  fever,  652 

maternal,     21.     See    also     Maternal 
nursing. 

prolonged  rachitis  after,  116 
Nutrient  enema,  83 

amount  of  nourishment,  85 
method  of  giving,  83 
nourishment  not  to  be  used,  84 

to  be  used,  86 
peptonized  milk  for,  68 


Nutrition    and    growth    of    new-born 
infant,     17.     See     also     New-born 
infant,  nutrition  and  growth. 
disorders  of,  86 
Nutritional  errors  in  artificial  feeding, 
48 
in  tardy  hereditary  syphilis,  687 

Oatmeal  jelly,  formula  for,  70 
Obesity,  752 

treatment,  752 
Obstetric  paralysis,  547 
Obstinate  constipation,  treatment,  244 

vomiting,  gavage  in,  791 
Obstruction,  intestinal,  244 

laryngeal,  292 
Obstructive  jaundice,  265 
O'Dwyer  intubation  set,  639,  640 

on  intubation,  638 
Oidium  albicans,  162 
Oil,  castor,  782 

injections  in  constipation  in  bottle- 
fed,  241 

inunction  in  scarlet  fever,  653 
in  tetany,  497 
Oils,  method  of  administration,  782 
Olivier  on  weight  of  thymus,  423 
Ophthalmo-reaction     with     tuberculin 

in  tuberculosis,  702 
Opie  on  diabetes  mellitus,  735 
Oppenheimer  on  blood-pressure,  401 
Oppenheim's  disease,  153 
Opsonic  index,  798 
Opsonins,  797 
Orchitis,  462 
Ord  on  cretinism,  729 
Organic  heart  murmurs,  370 

sensation  in  new-born  infant,  42 
Orth    on    localization    of    lobar    pneu- 
monia, 322 
Orthostatic  albuminuria,  452 
Osgood  and  Lucas  on  acute  poliomye- 

Utis,  537 
Osier  on  cretinism,  728 

onlithemia,  709 

on   Naunyn's  exercise  in  empyema, 
825 

on  polycythemia  in  congenital  cya- 
nosis, 401 
Osteomyelitis,    staphylococcus   vaccine 

in,  799 
Otitis,  acute,  601 

bacteriology,  601 


INDEX 


897 


Otitis,  acute,  complications,  603 
course,  603 

delayed  resolution  in,  605 
diagnosis,  603 
earache  in,  602 
etiology,  601 
fever  in,  602 
prognosis,  603 
symptoms,  602 
treatment,  603 
operative,  604 
post-operative,  604 
types,  601 
as  cause  of  elevation  of  temperature, 

749 
chronic,  suppurative,  605 

treatment,  606 
in  influenza,  674 
in  lobar  pneumonia,  325 
in  measles,  621 
in  scarlet  fever,  648 
treatment,  654 
staphylococcus  vaccine  in,  799 
Otten  on  pneumococcus,  321 
Out-door  treatment  of  marasmus,  89 
Out-of-doors,  days  for,  762 
Overfeeding,  110 

Oxygen  in  bronchopneumonia,  342 
Oxyuris  vermicularis,  248 

Pacifier,  use  of,  478 
Pack,  cool,  777 

in  typhoid  fever,  666 
Packs  in  scarlet  fever,  653 
Paine  and  Poynton  on  bacteriology  of 
chorea,  519 
on  diplococcus  in  rheumatism,  710 
Pains,  growing,  709 
Palpation  in  acute  endocarditis,  379 
in  bronchopneumonia,  334 
in  diseases  of  heart,  370 
in  lobar  pneumonia,  327 
of  chest,  303 
of  lungs,  303 
of  thymus  gland,  424 
Palsies,  cerebral,  513.     See  also  Paraly- 
sis, cerebral. 
Paltauf   on   cause   of   death   in   status 
lymphaticus,   426 
on  tetany,  493 
Pancreas,  tuberculosis  of,  364 
Papper  and  Landsteiner  on  acute  polio- 
myelitis, 536 
57 


Paracelsus  on  chorea,  518 

on  cretinism,  727 
Paralysis,  cerebral,  513 

acquired  form,  515-517 
birth  form,  513-515 
prenatal  form.  513 
Erb's,  547 
facial,  546 

infantile,    535.     See    also    Poliomye- 
litis, acute. 
obstetric,  547 
progressive  bulbar,  527 
wasting,  526 
Paralytic  ileus,  245 
treatment,  202 
Parameningococcus     in     cerebrospinal 

meningitis,  558 
Paraphimosis,  461 
Parasites,  eosinophilia  from,  399 
intestinal,  247 

as  cause  of  convulsions,  484 
blood  in  infections  by,  247 
Park  and  Krumwiede  on  bovine  tuber- 
culosis, 691 
Park  and  Zingher  on  blood  transfusion, 
787 
on  Schick  reaction,  628 
Park  on  intestinal  diseases  of  summer, 

217 
Parotitis,  611-613 
Paroxysmal  hemoglobinuria,  436 
Parrot  on  chondrodystrophia,  725 

on  sclerema  neonatorum,  145 
Passive  exercises  for  constipation,  844 

in  anterior  poliomyelitis,  842 
Pasteurization  of  milk,  74 

advantages  and  value  of,  75 
effect  on  assimilation,  77 
Pasteurizer,  Freeman's,  75 
Pastia  on  acute  poliomyelitis,  537 
Patellar   reflex   in   cerebrospinal    men- 
ingitis, 562 
Pavor  diurnus,  470 

nocturnus,  471 
Payne  and  Poynton  on  bacteriology  of 

acute  endocarditis,  378 
Peabody  and  Draper  on  blood  in  acute 

poliomyelitis,  536 
Peabody,  Draper  and  Dochez  on  acute 

poliomyelitis,  398,  536,  538,  539,  541 
Pearce  on  icterus  neonatorum,  144 
Pediculi  capitis,  574 
Peliosis  rheumatica,  713 


898 


INDEX 


Pellagra,  738 

Pemphigus  neonatorum,  579 

Pen,  exercise,  767 

Peptonized  milk,  68 

Percentage  gruel  flours,  formulas  for,  70 

Percussion,  303 

of  chest,  303 

of  lungs,  303 
Perforation  in  typhoid  fever,  660 
Peri-arthritis,  acute,  diagnosis,  757 

in  lobar  pneumonia,  325 
Pericarditis,  374 

bacteriology,  374 

diagnosis,  375 

in  lobar  pneumonia,  325 

in  scarlet  fever,  648 

pathology,  374 

percussion  in,  376 

physical  signs,  375 

prognosis,  376 

purulent  type,  treatment,  377 

symptoms,  375 

treatment,  376 
Pericardium,  adherent,  393 
Periodic  fever,  720 

as  cause  of  elevation  of  tempera- 
ture, 749 

vomiting,  715.     See  also  Cyclic  vomit- 
ing. 
Periostitis  in  tardy  hereditary  syphilis, 

687,  688 
Peristaltic  wave  in  pyloric  stenosis,  189 

method  of  obtaining,  190 
Peritoneum,  diseases  of,  172 

sepsis  of,  in  new-born,  146 

tuberculosis  of,  364 

chronic,    695.     See    also   Tubercu- 
lous -peritonitis,  chronic. 
Peritonitis,     acute,     appendicitis    and, 

differentiation,  254 
general,  256 

as  complication,  256 

in  lobar  pneumonia,  325 

leukocytosis  in,  398 

tuberculous,  chronic,  695.     See  also 
Tuberculous  peritonitis,  chronic. 
Peritonsillar  abscess,  283 
Perlin  on  blood  in  new-born,  394 
Permanent  teeth,  170 
Pernicious  anemia,  408 
Persistent  cough,  272 
Pertussis,     614.    See     also     Whooping 
cough. 


Petechial  fever,  557 

Peterson    on    mental    development    of 

newly  born,  42-44 
Petit  mal  type  of  epilepsy,  532 
Pfaundler  on  anatomy  of  stomach  in 
new-born,  172 
on  capacity  of  stomach,  172 
on  pyloric  stenosis,  185,  187 
Pfeiffer  on  Bacillus  influenzae,  670 
Phagocytic  index,  798 
Pharyngeal  tonsils,  279 
Pharyngitis,  274 

Phenacetin  in  typhoid  fever,  665 
Phillipp  on  carcinoma,  751 
Phimosis,  460 

as  cause  of  convulsions,  484 
Physical     development     of     new-born 

infant,  42 
Pianese  and  NicoUe  on  splenomegaly, 

263 
Picking  of  finger-tips,  478 
Piersol     on    anatomy    of    pharyngeal 

tonsils,  279 
Pigeon-breast,  302 

in  rachitis,  118,  119 
Pin-worms,  248 
Plasmodium  malarise,  666 

species  of,  667 
Platinger  on  leukocytosis  in  measles,  400 
Playfair    on    siphon    drainage    in    em- 
pyema, 356 
Pleura,  adherent,  as  cause  of  cough,  273 
Pleurisy,  appendicitis  and,  differentia- 
tion, 254 
counterirritants  in,  776 
dry,  349 

empyema  and,  differentiation,  354 
fibrinous  acute,  349 
primary,  348 
rheumatic,  713 
secondary,  348 
aspiration  in,  351 
auscultation  in,  350 
bacteriology,  349 
diagnosis,  350 
etiology,  348 

exploratory  puncture  in,  35 
pathology,  349 
percussion  in,  350 
symptoms,  349 
treatment,  350 
with  effusion,  treatment,  351 
serous,  acute,  349 


INDEX 


899 


Pleurisy,  tuberculous,  349 

ultimate  results  of  treatment,  348 

with  effusion,  349 

with    purulent    effusion,     351.     See 

also  Empyema. 
Pleuritic  effusion  in  lobar  pneumonia, 

327 
Pneumobacillus  of  Friedlander,  321 
Pneumococcus,  321 

infection  of  lungs,  acute,  316 
Pneumonia,  320 

acute,   appendicitis  and,   differentia- 
tion, 254 
catarrhal,    332.     See    also    Broncho- 
pneumonia. 
central,  326 
climate  in,  773 

empyema  and,  differentiation,  354 
hypostatic,  345 
interstitial,  342 

auscultation  in,  343 

diagnosis,  343 

pathology,  342 

percussion  in,  343 

prognosis,  344 

pulmonary  tuberculosis  and,  differ- 
entiation, 343 

symptoms,  343 
leukocytosis  in,  397 
lobar,  320 

abortive  type,  323 

acidosis  in,  325 

auscultation  in,  326 

bacterial  etiology,  321 

bowels  in,  328 

bronchopneumonia    and,    differen- 
tiation, 336 

clothing  in,  328 

cold  air  in,  328 

complications,  324 

consolidation  of  lungs  in,  326 

counterirritation  in,  328 

delayed  crisis  in,  324 

delirium  in,  324 

diagnosis,  326 
differential,  327 

diarrhea  in,  324 

duration  of  attack,  323 

empyema  in,  325,  353 

etiology,  321 

fever  in,  treatment,  329 

gavage  in,  331 

heart  stimulants  in,  329 


Pneumonia,  lobar,  hydrotherapy  in,  329 

hypodermic  stimulation  in,  331 

localization  of  lesions,  322 

meningitis  in,  325 

mustard  plaster  in,  328 

myocarditis  in,  325 

otitis  in,  325 

palpation  in,  327 

pathology,  321 

percussion  in,  326 

peri-arthritis  in,  325 

pericarditis  in,  325 

peritonitis  in,  325 

physical  signs,  326 

pleuritic  effusion  in,  327 

predisposition  to,  321 

prognosis  in,  326 

respiration  in,  323 

sick-room  in,  328 

specific  medication  in,  331 

stage  of  congestion  in,  321 
of  gray  hepatization  in,  321 
of  red  hepatization  in,  321 
of  resolution  in,  322 

stupor  in,  324 

symptoms,  322 
unfavorable,  324 

temperature  in,  322 
low,  324 

treatment,  327 

tympanites  in,  324 

vocal  fremitus  in,  327 

vomiting  in,  324 
Pneumothorax,  345 
Poisoning,  ivy,  571 

rhus,  571 
Polioencephalitis,  539 
Poliomyelitis,  acute,  535 

abortive,  538 

age  incidence,  538 

blood  findings  in,  536 

bulbar  spinal,  538 

cerebral,  538 

cerebrospinal  fluid  in,  536 

communicability,  541 

course,  540 

electricity  in,  541 

electric  reactions  in,  540 

etiology,  535 

exercises  in,  542,  841 

fever  in,  538 

human  serum  in,  541 

inimunity  in,  537 


900 


INDEX 


Poliomyelitis,  acute,  incubation  period, 
538 
leukocytosis  in,  536 
massage  in,  542,  843 
nasal  mucous  membrane  in  trans- 
mission, 537 
orthopedic  treatment,  542 
pathology,  535 
prognosis,  540 
quarantine  in,  541 
seasonal  influences,  538 
symptoms,  538 
transmission,  536 
treatment,  541 
type  of  cases,  537 
virus  in,  537 
chronic  anterior,  526 
leukocytosis  in,  398 
scurvy  and,  differentiation,  114 
Pollen  anaphylaxis  in  hay-fever,  301 

disease,  301 
PoUinosis,  301 

Polycythemia  in  congenital  heart  dis- 
ease, 401 
Polymorphonuclear  neutrophiles,  395 
Polyneuritis,    542.     See    also    Neuritis, 

multiple. 
Polyp,  umbilical,  154 
Polyuria,  734 

Porak  on  chondrodystrophia,  725 
Porencephalus,  500 
Pork  tape-worm,  249 
Port-wine  stain,  598 
Position  in   bed,  diagnostic  value,  131 
Posthemiplegic  chorea,  518 
Posture,   bad,  ■  correct  sitting  to   over- 
come, 812 
standing  to  overcome 
exercise  in,  809 
lying  in  good  position  to  correct, 

812 
shot-bag  exercise  in,  811 
static  exercises  for,  811 
walking  movements  for,  778 
effect  of  clothing  on,  807 
in  exercise,  806 
in  school,  809 
in  sleep,  808 
Potassium  chlorate  in  stomatitis,  166 
dangers,  166 
iodid,  782 
Pott  on  tetany,  493 
Powder,  toilet,  formula  for,  569 


Poynton  and  Paine  on  bacteriology  of 
acute  endocarditis,  378 
on  bacteriology  of  chorea,  519 
on  diplococcus  in  rheumatism,  710 
Poynton    on    citrate    of   soda   in   milk 

adaptation,  63 
Pratt  on  hemophilia,  413 
Precocious  maturity,  456 

menstruation,  456 
Premature  infant,  artificial  heat  for,  140 
feeding  of,  141 
fresh  air  for,  141 
prevention  of  infection,  141 
room  temperature  for,  141 
Prenatal  form  of  cerebral  paralysis,  513 
Prickly  heat,  569 
Prizner  and  Lucas  on  measles,  620 
Proctitis,  261 
catarrhal,  261 
membranous,  261 
ulcerative,  261 
Progressive  amyotrophy,  526,  530.     See 
also  Amyotrophy,  progressive. 
bulbar  paralysis,  527 
muscular  atrophies,  526 
spinal  muscular  atrophy,    526.     See 
also  Muscular  atrophy,   progressive 
spinal. 
Prolapse  of  rectum  and  anus,  258 
Proprietary  foods,  71 

addition  of  fresh  cow's  milk,  73 
beef,  73 
dried  milk,  72 
Prosek  on  scarlet  fever,  643 
Proteid    as    cause    of    constipation    in 
bottle-fed,  240 
milk    in    gastro-enteric    intoxication, 

201 
of  modified  cow's  milk,  55 
Proteids  of  breast-milk,  32 

of  cow's  milk,  49 
Protein  milk,  65 
Pseudoleukemic  anemia  of  von  Jaksch, 

406 
Pseudomembranous  ileocolitis,  222 
Pseudomuscular  hypertrophy,  530 

waddling  gait  in,  531 
Pseudoparalysis,  syphilitic,  681 
Psoriasis,  597 
Ptoses    of   stomach   in  older  children, 

177-180 
Pulmonary  abscess,  360 
gangrene,  360 


INDEX 


901 


Pulmonary  stenosis,  371 

tuberculosis,    361.     See   also    Tuber- 
culosis, 'pulmonary. 
Pump,  breast,  35 

Puncture,     exploratory,     in    secondary 
pleurisy,  350 
lumbar,  566.     See  also  Lumbar  punc- 
ture. 
reaction  in  tuberculosis,  701 
Purpura,  409 
lulminans,  409 
hemorrhagic,  409 
Henoch's,  409 
simple,  409 
Pus  in  urine,  436 

Pyelitis,  453.     See  also  Pyelocystitis. 
Pyelocystitis,  453 
age  incidence,  453 
as  cause  of  elevation  of  temperature, 

749 
diagnosis,  455 
duration,  455 

elevation  of  temperature  in,  454 
etiology,  453 

injection  of  Bacillus  coli  in,  801 
sex  in,  453 
symptoms,  454 
time  required  for  cure,  456 
treatment,  455 
vaccine,  456 
Pyloric    spasm,    hypertrophic    pyloric 
stenosis  and,  differentiation,  190 
treatment,  medical,  193 
stenosis,  185 

age  incidence,  185 
catheter  feeding  in,  193 
constipation  in,  188 
diagnosis,  189 
diet  in,  192 
etiology,  187 

hypertrophic    combined,    obstruc- 
tion and,  differentiation,  191 
pathology,  187 
peristaltic  wave  in,  189 

method  of  obtaining,  190 
prognosis,  191 

in  combined  cases,  192 
in  spasmodic  cases,  192 
with  palpable  tumor,  191 
pyloric  spasm  and,  differentiation, 

190 
rectal  medication  in,  193 
retention  of  food  in,  188 


Pyloric  stenosis,  sex  incidence,  186 

symptoms,  188 

treatment,  192 

tumor  in,  190 

vomiting  in,  188,  219 

weight  loss  in,  189 
Pyogenic  infection  as  cause  of  chronic 

rhinitis,  269 
Pyonephrosis,  439 
Pyrexia  in  acute  illness,  136 
Pyromania,  498 
Pyuria,  436 

Quarantine  in  acute  poliomyelitis,  541 

in  diphtheria,  634 

in  influenza,  676 

in  measles,  624 

in  scarlet  fever,  649 

in  varicella,  611 
Quest  on  spasmophilia,  489 
Quincke  on  icterus  neonatorum,  144 
Quincke's  needle  for  lumbar  puncture, 

566 
Quinin,  783 
Quinsy,  283 
Quiserne  on  polycythemia,  401 

Rach  on  acute  luetic  meningitis,  706 
Rachford  on  cyclic  vomiting,  715 
Rachitic  chest,  302 

rosary,  118 
Rachitis,  115 

after  first  year,  116 

after  prolonged  nursing,  116 

age  of  incidence,  115 

as  cause  of  convulsions,  483 

associated  with  other  diseases,  117 

bone  changes  in,  118,  119 

cod-liver  oil  in,  121 

constitutional  disorders  in,  119 

craniotabes,  118,  119 

cretinism  and,  differentiation,  120 

deformities  in,  treatment,  122 

diagnosis,  119 

diet  in,  120 

drugs  in,  122 

etiology,  116 

Harrison's  grooves  in,  118 

hydrocephalus    and,    differentiation, 
120 

hygiene  in,  121 

in  breast-fed,  116 

in  etiology  of  tetanus,  492 


902 


INDEX 


Rachitis,    mongolianism    and,  differen- 
tiation, 120 
nutritional  errors  in  etiology,  116 
pathology,  117 
pigeon-breast  in,  118,  119 
prognosis,  120 
racial  predisposition,  116 
theories  of  pathogenesis,  117 
treatment,  120 
Rales,  307     ■  ■ 

moist,  307 
mucous,  307 
musical,  307 
sibilant,  307 
sonorous,  307 
squeaking,  307 
Ramsey  on  pyloric  stenosis,  187  . 
Ramsted  operation  in  pyloric  stenoses, 

192 
Rarefied  air  apparatus  in  emphysema, 

829 
Rash  in  acute  hereditary  syphilis,  680 
in  German  measles,  624 
in  measles,  621 
delayed,  625 
in  varicella,  610 
Reaction.     See  Test. 
Reckzan  on  blood  findings  in  scarlet 

fever,  400 
Record  antitoxin  syringe,  633 

history,  132 
Rectal  feeding,  83 

amount  of  nourishment,  85 
in  acute  illness,  136 
method  of  giving,  83 
nourishment  not  to  be  used,  84 
to  be  used,  85 
injections  in  oxyuriasis,  248 
medication  in  laryngismus  stridulus, 
488 
in  pyloric  stenosis,  193 
Rectum  and  anus,  prolapse  of,  258 
in  children,  258 

inflammation  of,  261.     See  also  Proc- 
titis. 
Rectus,  spastic  right,  in  appendicitis, 

253 
Recurrent    vomiting,     715.     See    also 

Cyclic  vomiting. 
Red  cells,  394 

hepatization  in  lobar  pneumonia,  321 
Reduplication  of  esophagus,  171 
Reflex  eczema,  593 


Regurgitation,  aortic,  heart  murmur  in, 
372 
mitral,  heart  murmur  in,  371 
treatment,  391 
Regurgitant  murmur,  370 
Resonance  of  chest,  303 

tympanitic,  304 
Respiration,  artificial,  in  asphyxia  neona- 
torum, 150 
in  cerebrospinal  meningitis,  560,  562 
in  lobar  pneumonia,  323 
Respiratory  exercises  in  emphysema,  828 
m.urmur  in  bronchopneumonia,  333 
tract,  diseases  of,  267 
Restlessness  in  acute  hereditary  syphilis, 

679 
Retention  of  urine,  430 
Retropharyngeal  abscess,    acute,    275- 
277 
spasmodic  croup  and,  differentia- 
tion, 288 
adenitis,  275 

spasmodic  croup  and,  differentia- 
tion, 288 
Rheumatic  fever,  721 
pleurisy,  713 
symptom-complex,  709 
Rheumatism,  709 
acute,  721 

articular,  counterirritants  in,  776 
age  incidence,  710 
bathing  in,  711 
chorea  and,  relation,  519 
diet  in,  710 
drugs  in,  711 
etiology,  710 
leukocytosis  in,  398 
recurrent  bronchitis  in,  712 
scurvy  and,  differentiation,  114 
treatment,  710 
Rheumatoid  arthritis,  724 
Rhinitis,  acute,  267 
chronic,  269 

in  acute  hereditary  syphilis,  679 
in  adenoids,  294 

specific,  acute  rhinitis  and,  differen- 
tiation, 267 
Rhus  poisoning,  571 
Ribbert  on  carcinoma,  751 
Rice-water,  formula  for,  70 
Rickets,  115.     See  also  Rachitis 
fetal,  725 
scurvy, 112 


TNDEX 


903 


Rieder  on  leukocytes,  395 

Rilliet     and     Barthez     on     congenital 

laryngeal  stridor,  491 
Ring-worm,  575 

of  scalp,  576 

of  tongue,  167 
Roentgen-ray    examination    in    ptoses 
and    dilatation    of    stomach    in 
older  children,  177 
in  status  lymphaticus,  427 

treatment  of  status  lymphaticus,  428 
of  tinea  tonsurans,  578 
Rohn  on  percussion  of  thymus  gland, 

427 
Rolleston  on  blood-pressure,  401 
in  contagious  diseases,  402 
RoUier  on  heliotherapy,  366 

treatment  of  surgical  tuberculosis,  698 
Romanowitch   on  trichiniasis,  251 
Room,  sick-,  in  acute  illness,  134 

temperature  for  exercise,  803 
for  premature  infants,  141 
in  acute  illness,  134 
Rosary,  rachitic,  118 
Rose  and  Mendel  on  creatin  excretion 
in  starvation,  663 

spots  in  typhoid,  659 
Rosenel  on  tuberculosis,  693 
Rosenstern  on  tetany,  493 
Rotch   on   age   in   cerebrospinal   men- 
ingitis, 559 

on  capacity  of  stomach,  172 
Rotheln,  624 

Round  shoulders,  exercises  for,  817 
Round-worms,  247 
Roux  on  diphtheria,  626 
Rubbing  of  finger-tips,  478 
RubeUa,  624 
Rudolf  on  coagulation  time  of  blood, 

402 
Ruminations,  220 
Runyon  on  cyclic  vomiting,  715 
Russell  and  Babcock  on  proteid  change 

in  centrifugal  cream,  74 
Russell  on  antityphoid  inoculation,  800 

on  dietetics  and  food  economics,  22 

on  typhoid  carriers,  657 

Sabbatini  on  tetany,  493 

Saber    deformity   in   tardy   hereditary 

syphilis,  687 
Sachs  on  amaurotic  family  idiocy,  507 

on  cerebral  paralysis,  514 


Sachs  on  Erb's  paralysis,  548 
on  Friedreich's  ataxia,  549 
on  hydrocephalus,  509,  512 
on  hysteria,  498 
on  microcephalus,  500 
on  primary  dystrophies,  530 
Saddle  nose  in  tardy  hereditary  syphilis, 

688 
Sahli  on  blood   coagulation   in   hemo- 
philia, 412 
Sainton  on  true  dwarfism,  733 
Salicylate  of  soda,  781 
Salts,  ammonium,  782 
Salvarsan  in  acute  hereditary  syphilis, 

683,  684 
Sanitarium  treatment  of  tuberculosis, 

774 
Sappey  on  thymus  in  new-born,  423 
Sarcoma  of  brain,  502 
Satterthwaite's     method     of     artificial 

respiration  in  emphysema,  828 
Sauerbeck  on  diabetes  mellitus,  735 
Scabies,  572 
Scala  on  pellagra,  738 
Scales,  baby,  41 
Scalp,  ring-worm  of,  576 
Scapulohumeral    type    of    progressive 

amyotrophy,  530 
Scarlatina,  643.     See  also  Scarlet  fever. 
Scarlet  fever,  643 
adenitis  in,  648 

treatment,  654 
albuminuria  in,  648 
arthritis  in,  648 

treatment,  656 
bacteriology,  643 
bowels  in,  652 
bronchopneumonia  in,  648 
care  of  nose  and  throat  in,  654 
clothing  in,  651 
complications,  647 

treatment,  654 
contagion,  644 
control  of  fever  in,  653 
desquamation  in,  646 

second,  646 
diagnosis,  647 
diet  in,  651 
diphtheria  in,  648 
endocarditis  in,  648 
etiology,  643 

gastro-intestinal      symptoms      in, 
659 


904 


INDEX 


Scarlet    fever,    German    measles    and, 
differentiation,  625 

heart  involvement  in  treatment,  655 

history,  643 

incubation  period,  645 

kidney  of,  442 

laxatives  in,  652 

leukocytosis  in,  400 

membranous    non-diphtheric     an- 
gina in,  647 

milk  diet  in,  651 

mortality,  649 

myocarditis  in,  648 

nephritis  in,  648 

nephritis  in,  treatment,  655 

nursing  in,  652 

oil  inunction  in,  653 

otitis  in,  648 
treatment,  654 

packs  in,  653 

pericarditis  in,  648 

prophylaxis,  649 

quarantine  in,  649 

quiet  in,  652 

second  attacks,  645 

second  desquamation  in,  646 

serum  treatment,  652 

severity,  647 

sick-room  in,  650 

stimulants  in,  653 

strawberry  tongue  in,  647 

streptococcus  vaccine  in,  800 

surgical,  656 

susceptibility,  645 

symptomatology,  645 

transmission,  644 

treatment,  650 

tub-baths  in,  653 

urine  examination  in,  651 
Schaffer  on  glandular  fever,  419 
Schaudinn  and  Hoffmann  on  Spirochseta 

pallida,  677 
Schick  on  serum  disease,  708 
test  in  diphtheria,  627-630 
Schiff  on  blood  in  new-born,  394 

on  cretinism,  727 
Schloss  on  idiosyncrasy  to  food,  79 
School  in  chorea,  521 
in  habit  spasm,  525 
posture  in,  809 
Schools  for  training  nursery  maids,  38 
Schultze's  method  of  artificial  respira- 
tion in  asphyxia  neonatorum,  150 


Schultz's  sign  in  tetany,  495 
Scipiades  on  blood  in  new-born,  394 
Scleredema,  sclerema  neonatorum  and, 

differentiation,  145 
Sclerema  neonatorum,  145 

scleroderma    and,    differentiation, 
145 
Sclerosis,    amytrophic  lateral,  526,  527 
Scoliosis,  820 

Adams  position  in,  822 

diagnosis,  821 

exercises  for,  822 

key-note  position  in,  824 

treatment,  822 
Scorbutus,  111.     See  also  Scurvy. 
Scrambled  egg  stools,  46 
Scraped  beef,  formula  for,  70 
Scratch  skin  test  in  hay-fever,  302 
Scripture  on  tics,  524 
Scurvy,  111 

age  of  incidence,  112 

Alpine,  738 

diagnosis,  differential,  114 

etiology,  112 

infantile,  112 

pathology,  112 

poliomyelitis  and,  differentiation,  114 

prognosis,  114 

rheumatisn  and,  differentiation,  114 

symptoms,  113 

syphilis  and,  differentiation,  114 

trauma  and,  differentiation,  114 

treatment,  114 
Scurvy-rickets,  112 
Seborrhea,  595 

capitis,  595 

intertrigo,  596 
Seborrheic  eczema,  598 
Sedatives  in  convulsions,  486 
Sedgwick  on  strapping  jaw  in  rumina- 
tion, 220 
Seguin  on  Fowler's  solution  in  chorea, 

522 
Seibert  on  diet  in  typhoid,  662 

on  lavage,  788 
Seligmiiller  on  tetany,  493 
Senile  chorea,  518 

Sensation  in  cerebral  paralysis,  516 
Sepsis  in  new-born,  146 
Septic  sore  throat,  286 
Septicemia,      general,     staph  jdococcus 

vaccine  in,  799 
Sergeant  on  blood-pressure,  401 


INDEX 


905 


Serous  meningitis,  565 
Serum,  Flexner's,  in  cerebrospinal  men- 
ingitis, 563-565 

human,  in  acute  poliomyelitis,  541 

treatment  of  hemorrhagic  diseases  of 
new-born,  160 
technic,  161 
of  scarlet  fever,  652 
Shaffer    on    pathology    of    amaurotic 

family  idiocy,  508 
Sharpe  on  decompression  convulsions, 
484 

on  Erb's  paralysis,  548 
Shennan  on  pathology  of  acute  diffuse 
nephritis,  442 

on  tuberculous  meningitis,  553 
Shield,  nipple-,  31 

vaccination,  761 
Shore     on     streptococcus     vaccine     in 

erysipelas,  800 
Shoulders,  round,  exercises  for,  817 
Sibilant  rales,  301 
Sick-room  in  acute  illness,  134,  137 

in  bronchopneumonia,  337 

in  lobar  pneumonia,  328 

in  scarlet  fever,  650 
Siegert  on  rickets,  115 
Sight  in  new-born  infant,  42 
Sigmoid,  long,  208 
Sinus  thrombosis,  606 
Sinuses,  diseases  of,  as  cause  of  chronic 

rhinitis,  270 
Siphon  drainage  in  empyema,  356 
advantages,  359 
technic,  357 
Skimmed  milk  mixtures,  57 
Skin,  care  of,  in  health,  568 

changes  in  tardy  hereditary  syphilis, 
686 

diseases  of,  568 

in  cerebrospinal  meningitis,  560 

reactions,  tuberculin,  in  infancy,  703 

sepsis  of,  in  new-born,  146 

test  in  hay-fever,  302 
Skull,    fracture   of,    depressed,    cephal- 
hematoma and,  differentiation,  143 
Sleep,  45 

for  delicate  children,  127 

inspection  during,  diagnosis  by,  132 

posture  in,  808 
Smell,  sense  of,  in  new-born  infant,  42 
Smith   and  LeWald  on  position  after 

feeding,  94 


Snuffles,  267 
Soda  bath,  780 

Sodium  bicarbonate  in  cyclic  vomiting, 
718 
bromid  in  whooping-cough,  618 
citrate  in  milk  adaptation,  63    • 
salicylate,  781 
in  chorea,  521 
Solids  of  cow's  milk,  49 
Solis-Cohen  on  leukocytosis  in  tuber- 
culosis, 398 
Sonorous  rdles,  307 
Soor,  162 

Sophian  on  serum  treatment  of  cere- 
brospinal meningitis,  564 
Sore  throat,  septic,  286 
streptococcus,  280 
Southworth     on     excessive     ammonia 

excretion,  100 
Spasm,  habit,  524 
Spasmodic  croup,  287 

antispasmodics  in,  291 
calomel  fumigations  in,  290 
cold  compresses  in,  290 
diagnosis,  differential,  288 
etiology,  287 
expectorants  in,  289 
laryngismus  stridulus  and,  differ- 
entiation, 288 
pathology,  287 

retropharyngeal  abscess  and,  differ- 
entiation, 288 
adenitis  and,  differentiation,  288 
steam  inhalations  in,  290 
symptoms,  287 
treatment,  288 
Spasmophilia,  489 
Spasmus  nutans,  472 
Specific  gravity  of  blood  in  new-born, 
394 
parotitis,  611-613 
vaginitis,  466 
Speech,     disturbance    of,     in    cerebral 
paralysis,  517 
exercise   for,    in   congenital    ataxias, 
840 
Spencer  on  success  in  life,  22 
Spermatic  cord,  hydrocele  of,  463 

encysted,  464 
Sphygmomanometer,  Faught's,  401 
Spina-bifida,  501 

Spinal  cord,  malformations  of,  499 
meningocele  of,  501 


906 


INDEX 


Spinal  muscular  atrophj',  progressive, 
526.     See   also  Muscular   atropMj, 
progressive  spinal. 
Spine,  lateral  curvature  of,  820.     See 
also  Scoliosis. 
tuberculosis  of,  diagnosis,  758 
Spirochseta  pallida,  677 
Spleen,  diseases  of,  263 

in  acute  hereditary  syphilis,  680 
in  Hodgkin's  disease,  414 
in  leukemia,  408 
in  tardy  hereditary  syphilis,  688 
in  typhoid  fever,  659 
tuberculosis  of,  63 
Splenomegaly,  263 
Splenomyelogenous  leukemia,  407 
Sponging,  cold,  in  fever,  776 

in  acute  illness,  134 
Spratling  on  epilepsy,  531 
Sprue,  162 

Sputum    in    pulmonary    tuberculosis, 
care  of,  366 
methods  of  obtaining,  362 
Squeaking  rales,  307 
St.  Vitus'  dance,  518.     See  also  Chorea. 
Stadelmann  on  icterus  neonatorum,  143 
Stain,  port-wine,  598 
Stammering,  525 
Staphylococcus  aureus,  332 
vaccine,  799 

in  antrum  disease,  799 
in  furunculosis,  799 
in  general  septicemia,  799 
in  local  suppuration,  799 
in  osteomyelitis,  799 
in  styes,  799 
Starch  and  opium  in  acute  ileocolitis,  226 
bath,  780 

digestion  in  young  infants,  68 
Starch-feeding,  66 
Status  lymphaticus,  424 

as  cause  of  convulsions,  484 
cause  of  sudden  death  in,  426 
diagnosis,  427 
etiology,  425 
pathology,  424 

roentgen-ray  examination,  427 
roentgen-ray  treatment,  428 
thymus  in,  424 
treatment,  428 
Steam  inhalations  in  bronchitis,  312 
in  bronchopneumonia,  338 
in  spasmodic  croup,  290 


Stenosis,  aortic,  murmur  in,  372 

congenital,  of  esophagus,  171 

mitral,  heart  murmur  in,  371 
treatment,  391 

of    pylorus,    183.     See    also    Pyloric 
stenosis. 

pulmonary,  371 
Stenotic  murmur,  370 
Sterilization  of  milk,  74 
Sterilizer,  Arnold,  75 
Sternocleidomastoid,  hematoma  of,  752 

treatment,  752 
Stethoscope,  308 

Bowles,  309 
Stick  reaction  in  tuberculosis,  701 
Stiles  on  uncinariasis,  247 
Still  on  polycythemia,  401 

on  pyloric  stenosis,  185,  187,  190 

on  rheumatic  complex,  709 

^  fever,  721 

on  rheumatoid  arthritis,  724 

on  tuberculosis,  694 

on  tuberculous  peritonitis,  695 
Still's  disease,  724 

treatment,  724 
Stilling  on  cretinism,  729 
Stimulant    inhalations   in   acute   spas- 
modic bronchitis,  319 
Stimulants,     heart,     in    bronchopneu- 
monia, 340 
in  chronic  valvular  disease,  392 
in  lobar  pneumonia,  329 

in  acute  enteric  intoxication,  203 

in  erysipelas,  584 
Stimulation,  hypodermic,  in  lobar  pneu- 
monia, 331 

in  acute  illness,  137 
Stoeltzner  on  tetany,  493 
Stomach,  anatomy  of,  172 

capacity,  172 

cough,  272 

dilatation  of,  chronic,  176    _ 

digestion,  172 
duration  of,  173 

dilatation  of,  in  older  children,  177- 
180 

diseases  of,  172 

hemorrhage  from,  182 

motility,  173 

ptoses  of,  in  older  children,  177-180 

tuberculosis  of,  363 

ulceration  of,  183 
Stomach-feeding,  substitutes  for,  81 


INDEX 


907 


Stomach-tube,  791 

Stomach-washing,  788.  See  also  Lavage. 

Stomach,  dilatation  of,  vomiting  from, 

219 
Stomatitis,  163 

aphthous,  163 

bacteriology,  163 

catarrhal,  163 

drugs  in,  165 

etiology,  163 

feeding  in,  165 

mouth -washing  in,  165 

mycotic,  162 

necrobiosis  in,  164 

potassium  chlorate  in,  166 
dangers,  166 

prognosis,  165 

symptoms,  164 

treatment,  165 
of  ulceration,  165 

types,  163 

ulcerative,  163 
Stone  in  bladder,  458 
Stools,  bacilli  in,  in  pulmonary  tuber- 
culosis, 363 

blood  in,  47 

breast  fed,  46 

cow's  milk,  46 

curds  in,  47 

hard  balls,  46 
constipated,  46 

mucus  in,  47 

scrambled  egg,  46 
Strait-jacket  in  eczema,  591 
Strauch  on  rumination,  220 
Strawberry  tongue  in  scarlet  fever,  647 
Streptococcus  sore  throat,  280 

vaccine,  799 

in  erysipelas,  800 
in  scarlet  fever,  800 
Strickler  on  tinea  tonsurans,  578 
Stridor,  congenital  laryngeal,  491 

in  laryngismus  stridulus,  487 
Strophanthus     in     bronchopneumonia, 
340 

in    chronic    valvular  heart   disease, 
393 

in  lobar  pneumonia,  330 
Strouse  on  diabetes  mellitus,  735 
Striimpell  on  acute  poliomyelitis,  539 

on  relation  of  chorea  to  rheumatism, 
519 
Strychnin,  783 


Styes,  staphjdococcus  vaccine  in,  799 
Styles  on  diphtheria,  627 
Subcutaneous  inoculation  with  tuber- 
culin in  diagnosis  of  tuberculosis, 
701 
emphysema,  347 
Sugar  of  modified  cow's  milk,  56 
Summer  clothing,  763 
instructions  for,  763 
intestinal  diseases  of,  prevention,  216 
resorts,  768 
second,  feeding  in,  105 
water  to  drink  in,  763 
Suppositories  in  constipation  in  nurs- 
lings, 239 
Suppression  of  urine,  430 
Suspension  of  bacteria,  798 
Sydenham  on  chorea,  518 
Sylvester's  method  of  artificial  respira- 
tion in  emphysema,  828 
in  empyema,  825 
Symptomatic  infantilism,  733 
Syphihs,  677 
acquired,  685 
acute  hereditary,  678 

acute  epiphysitis  in,  681 
arsenicals  in,  684 
arsenobenzol  in,  685 
convalescence  in,  683 
diarsenol  in,  685 
eosinophilia  in,  399 
fissures  in,  681 
hemorrhage  in,  681 
liver  in.  680 
mercury  in,  682-684 
mucous  patches  in,  681 
nails  in,  681 

neosalvarsan  in,  684,  685 
rash  in,  680 
restlessness  in,  679 
rhinitis  in,  679 
salvarsan  in,  683,  684,  685 
spleen  in,  680 
symptoms,  678 
treatment,  682 
later,  682 
as    etiologic    factor    in  hemorrhagic 

diseases  of  new-born,  158 
butyric-acid  test  for,  705 
complement-fixation  test  for,  705 
congenital,  678,  684.     See  also  Syphi- 
lis, acute  hereditary. 
scurvy  and,  diiferentiation,  114 


908 


INDEX 


Syphilis,  tardy  hereditary,  685 

blood-vessels  in,  686 

bones  in,  687,  688 

ear  changes  in,  686 

errors  in  nutrition  in,  687 

eye  changes  in,  686,  688 

Hutchinson's  teeth  in,  688 

liver  in,  688 

lymph-nodes  in,  686,  688 

Meniere's  disease  in,  686 

mixed  treatment,  689 

pathology,  686 

periostitis  in,  687,  688 

respiratory    mucous  "membrane 
in,  686 

saber  deformity  in,  687 

saddle  nose  in,  688 

skin  clianges  in,  686 

spleen  in,  688 

symptoms,  687 

teeth  in,  688 

treatment,  688 

viscera  in,  686 
Wassermann  test  for,  704 
Syphilitic  pseudoparalysis,  681 
Syringe,  antitoxin,  633 
Syringomyelocele,  501 

Tabes    dorsalis,    Friedreich's    disease 
and,  differentiation,  549 

mesenterica,  694 
Tache  cerebrale  in  cerebrospinal  men- 
ingitis, 561 
Taenia  elliptica,  249 

saginata,  249 

solium,  249 
Takasu  on  blood  in  new-born,  394 
Talipes  planus,  exercises  for,  844-846 

massage  in,  845 
Tannalbin  in  acute  ileocolitis,  224 
Tape-worm,  beef,  249 

fish,  249 

pork,  249 
Tape-worms,  249 
Tardy  malnutrition,  100 

of  syphilitic  origin,  689 
Tartar  emetic,  782 
Taste  in  new-born  infant,  42 
Tay  on  amaurotic  family  idiocy,  507 
Teeth,  169 

care  of,  169 

in  tardy  hereditary  syphilis,  688 

permanent,  170 


Teething  cough,  272 

Telangiectasis,  598.     See  also  Ncevus. 

Temperature,  744 

elevation   of,   encysted  empyema  as 
cause,  749 
from  active  exercise,  747 
intestinal  infection  as  cause,  749 
otitis  as  cause,  749 
periodic  fever  as  cause,  749 
pyelitis  as  cause,  749 
tuberculosis  as  cause,  749 
typhoid  fever  as  cause,  749 
unexplained,  749 
high,  in  acute  illness,  treatment,  136 
in  cerebrospinal  meningitis,  560,  562 
in  intussusception,  234 
in  lobar  pneumonia,  322 
in  measles,  621 
in  varicella,  610 
low,  in  lobar  pneumonia,  324 
normal,  744 

obscure  elevation  of,  747 
of  room  in  acute  illness,  134 
for  premature  infants,  141 
in  exercise,  803 
Teniasis,  248 

Test,  Schick,  in  diphtheria,  627-630 
butyric-acid,  for  syphilis,  705 
Noguchi's  luetin,  in  syphilis,  706 
complement-fixation  for  syphilis,  705 
tuberculin,  Calmette's,  703 

Detre's  differential  cutaneous,  702 
•Hamburger's,  701 
Moro  inunction,  702 
skin,  in  infancy,  703 
von  Pirquet's,  702 
Wassermann,  for  syphilis,  704 
Widal,  in  typhoid  fever,  707 
Testicle,  undescended,  462 

inguinal  hernia  and,  differentiation, 
755 
Testut  on  weight  of  thymus,  423 
Tetanus    antitoxin   in   tetanus   neona- 
torum, 157 
bacillus,  156 

electric  irritability  in,  495 
neonatorum,  156 
rachitis  in  etiology,  492 
Tetany,  491 

accoucheur  hand  in,  494 
as  cause  of  convulsions,  485 
age  incidence,  492 
bath  in,  498 


INDEX 


909 


Tetany,  Chvostek's  sign  in,  495 

climate  in,  497 

diagnosis,  495 

duration,  495 

etiology,  492 

muscle  irritability  in,  494 

oil  inunctions  in,  497 

prognosis,  496 

proteid  diet  in,  497 

Schultz's  sign  in,  495 

symptoms,  494 

tonics  in,  497 

treatment,  496 

Trousseau's  sign  in,  495 
Thayer  on  malaria,  667 
Therapeutics,  gymnastic,  803.   See  also 

Exercise. 
Therapeutic  measures,  771 

nihilism,  771 

value  of  climate,  773 
Thermometer,  bath,  779 
Thiemich's  lip  sign  in  spasmophilia,  490 
Thiemich  on  tetany,  493 
Thirst-hunger  in  new-born  infant,  42 
Thomas  strait-jacket  in  eczema,  591 
Thompson  and  Deaderick  on  pellagra, 

740 
Thompson  on  exercise,  803 
Thomson  on  hemorrhagic   diseases  of 
new-born,  159 

on  pyelocystitis,  454 
Thomson's  theory  of  pyloric  stenosis, 

187 
Thread-worm,  248 
Thrill  in  diseases  of  heart,  372 
Thoracic  breathing,  813 
Throat,  diseases  of,  267 

examination,  271 

irrigation  of,  278 

in  peritonsillar  abscess,  284 
indications,  278 
technic,  278 

septic  sore,  286 

sore,  streptococcus,  280 
Thrombosis,  sinus,  606 
Thrush,  162 
Thumb-sucking,  478 
Thymol  in  uncinariasis,  251 
Thymu.  gland,  423 

enlargement    of,     424.     See     also 
Status  lymiphaticus. 
Thyroid  treatment  in  cretinism,  731- 

733 


Tic,  524 

Tinea  circinata,  575 

tonsurans,  576 
Tongue,  geographic,  167 

ringworm  of,  167 
Tonsillar     diphtheria,    tonsillitis    and, 

differentiation,  281 
Tonsillitis,  280 

follicular,  acute,  280 
Tonsil,  abdominal,  252 
Tonsils,  anatomy,  279 

and  adenoids,   radical  removal,   298 
diseased,  permanently,  297 

necessity     for    operative    inter- 
ference, 297 
enlarged,    adenoids  associated  with, 

296 
faucial,  279 

hypertrophy  of,  chronic,  297 
lingual,  279 
pharyngeal,  279 
radical  removal  of,  298 
tubal,  279 
Top-milk   methods   of   milk   modifica- 
tion, 59 
formulas,  60 
Tracheal  cough,  273 
Transfusion,  blood,  786 

in  secondary  anemia,  404 
indications  for,  786 
prevention  of  hemolysis  in,  786 
Transitional  cells,  395 
Transmissible  diseases,  608 
Trauma,    scurvy    and,    differentiation, 

114 
Traumatic  eczema,  treatment,  589 

laryngitis,  291 
Traveling,  milk  for,  69 
Treponema  pallidum,  677 
Trichina  spiralis,  251 
Trichinella  spiralis,  251 
Trichiniasis,  251 
Trousseau's  sign  in  spasmophilia,  490 

in  tetany,  495 
Tubal  tonsils,  279 
Tub-baths  for  fever,  779 

in  scarlet  fever,  653 
Tuberculin  in  diagnosis  of  tuberculosis, 
701 
cutaneous  inoculation,  702 
eye  inoculation,  703 
subcutaneous  inoculation,  701 
skin  reactions  in  infancy,  704 


910 


INDEX 


Tuberculin  test,  Calmette's,  703 

Detre's  differential  cutaneous,  702 

Hamburger's,  701 

Moro  inunction,  702 

skin,  in  infancy,  703 

von  Pirquet's,  702 
treatment  of  tuberculosis,  801 
Tuberculosis,  691 
abdominal,  694 
acute    miliary,    typhoid    fever    and, 

differentiatio"n,  661 
as  cause  of  cough,  273 

of  elevation  of  temperature,  749 
avenues     of     entrance     of    bacillus, 

692 
bovine,  691 
climate  in,  774 
from  milk  infection,  693 
joint,  diagnosis,  758 
leukocytosis  in,  398 
of   cervical   lymph-nodes,  420 
of  hip,  diagnosis,  758 
of  kidney,  438 
of  mesenteric  gland,  694 
of  spine,  diagnosis,  758 
predisposing  causes,  692 
pulmonary,  361 

associated  lesions,  363 

bacilli  in  stool,  363 

bronchitis  and,  differentiation,  314 

climate  in,  364 

diagnosis,  362 

diet  in,  364 

empyema  and,  differentiation,  355 

heart  involvement  in,  363 

heliotherapy  in,  366 

hygiene  in,  365 

interstitial  pneumonia  and,  differ- 
entiation, 343 

intestinal  involvement  in,  364 

kidney  involvement  in,  364 

liver  involvement  in,  363 

pathology,  361 

prognosis,  363 

spleen  involvement  in,  363 

sputum  in,  care  of,  366 
methods  of  obtaining,  362 

symptoms,  361 

tonics  in,  365 

treatment,  364 
relative  frequency  in  different  sites, 

693 
sanitarium  treatment,  774 


Tuberculosis,  stomach  involvement  in, 
363 
surgical,  heliotherapy  in,  698 

Rollier's  treatment,  698 
tuberculin  in  diagnosis,  701 
cutaneous  inoculation,  702 
eye  inoculation,  703 
subcutaneous  inoculation,  701 
treatment,  801 
types  of  infections,  691 
Tuberculous  adenitis,  420 

caries  of  cervical  vertebra,  278 
meningitis,  553.     See  also  Meningitis, 

tuberculous. 
peritonitis,  chronic,  695 
age  incidence,  696 
ascitic  type,  696 
diagnosis,  697 
etiology,  695 
heliotherapy  in,  698 
pathology,  695 
plastic  type,  696 
prognosis,  697 
symptoms,  696 
treatment,  surgical,  698 
types  of  lesions,  696 
pleurisy,  349 
Tumors  of  brain,  502.     See  also  Brain 

tumors. 
Tunica  vaginalis,  hydrocele  of,  464 
Tunnicliff  and  Weaver  on  necrobiosis, 
.166 
on   streptococcus  vaccine  in  scarlet 
fever,  800 
Turbinated  bones,  hypertrophy  of,  as 

cause  of  chronic  rhinitis,  269 
Turpentine  in  bronchopneumonia,  338 
Tussis  infantum,  614 

perennis,  614 
Tympanites  in  lobar  pneumonia,  324 
Tympanitic  dulness  of  chest,  304 

resonance  of  chest,  304 
Typhoid  bacillus,  657 

dead,  inoculation  of,  800 
fever,  657 

acute    miliary    tuberculosis     and, 

differentiation,  661 
as  cause  of  temperature  elevation, 

749 
bacteriology,  657 
bathing  in,  661,  666 
care  of  bowels  in,  664 
of  discharges  in,  661 


INDEX 


911 


Typhoid  fever,  carriers,  657 
complications,  660 
control  of  fever  in,  665 
cool  pack  in,  666 
diagnosis,  differential,  660 
diagnostic  signs,  660 
diarrhea  in,  treatment,  664 
drugs  in,  664 
duration   of   immunity    conveyed, 

659 
empyema  and,  differentiation,  355 
feeding  in,  661 
heart  stimulants  in,  665 
hemorrhage  in,  treatment,  666 
intestinal  hemorrhage  in,  660 

lavage  in,  666 
leukocytosis  in,  398 
milk  in,  663 
•mortaUty,  661 
mouth  toilet  in,  661 
nervous  symptoms,  659 
pathology,  658 
perforation  in,  660 

treatment,  666 
phenacetin  in,  665 
pulse  in,  659 
rose  spots  in,  659 
spleen  in,  659 
symptoms,  658 
temperature  in,  660 
transmission,  658 
treatment,  661 
vaccination  against,  658 

advisability,  659 
Widal  reaction  in,  707 
Typhus  syncopalis,  557 

Ulcer,  duodenal,  184 
Ulceration  at  angle  of  mouth,  168 

of  stomach,  183 
treatment,  165,  183 
Ulcerative  proctitis,  261 

stomatitis,  163 
Ulcus,  Egyptacum,  625 

Syracum,  625 
Umbilical  cord,  care  of  stump,  41 
hernia  of,  753 

granuloma,  154 

hernia,  753 

congenital,  754 

polyp,  154 
Umbilicus,  sepsis  of,  in  new-bom,  146 
Uncinaria  Americana,  250 


Uncinariasis,  250 
Underwood's  disease,  145 
Undescended  testicle,  462  i 

Unger    and    Koplik    on    Schick    test, 

628 
Unger  on  blood  transfusion,  786 
Unpalatable  drugs,  781 
Urea  excretion  in  acute  diffuse  nephritis, 

448 
Uremia,  convulsions  in,  484 

in  acute  diffuse  nephritis,  444 
treatment,  448 
Urethra,  atresia  of,  469 
Urination,  continence  established,  430 

difficult,  430 

normal  variations  of,  429 

painful,  430 
Urine,  429 

blood  in,  436 

examination,  in   acute   diffuse  neph- 
ritis, 444 
in  scarlet  fever,  651 
in  acute  illness,  135 

in  acute  diffuse  nephritis,  443 

in  diabetes  mellitus,  736 

in  gastro-enteric  intoxication,  195 

incontinence  of,  432-434 

method  of  collecting,  430 

observations  on,  429 

pus  in,  436 

retention,  430 

suppression,  430 
Urogenital  system,  diseases  of,  429 
Urticaria,  570 

after    injection    of    diphtheria    anti- 
toxin, 635 

giant,  570 

Vaccination,  760 

after-treatment,  760 

against  typhoid  fever,  658 

complications,  761 

constitutional  disturbances  from,  761 

in  typhoid,  advisability,  659 

local  applications,  761 

method,  760 

shield,  761 

site,  760 
Vaccine,  gonococcus,  800 

meningococcus,  800 

preparation  of,  798 

staphylococcus,  799.    See  also  Staphy- 
lococcus vaccine. 


912 


INDEX 


Vaccine,  streptococcus,  799.      See  also 
Streptococcus  vaccine. 
treatment,  797 

fundamental  principles,  797 
in  gonorrheal  vulvovaginitis,  469 
of  cerebrospinal  meningitis,  565 
of  pyelocystitis,  456 
of  whooping-cough,  617 
Vagina,  atresia  of,  469 
Vaginal  hydrocele,  common,  464 
Vaginitis,  specific,  466 
Valvular  disease,  chronic,  of  heart,  389 
constructive     medication     in, 

392 
diagnosis,  390 
diet  in,  391 
digitalis  in,  392 
drugs  in,  391 
etiology,  389 
heart  rest  in,  392 

stimulants  in,  392 
prognosis,  390 
strophanthus  in,  393 
symptomatology,  389 
treatment,  390 
heart  murmurs,  370 
Van  Cott  and  Lind  on  trichiniasis,  251 
Vapor  treatment  in  measles,  624 

of  influenza,  677 
Vaquez  on  polycythemia,  401 
Varicella,  609-611 
Veeder  on  duodenal  ulcer,  184 
on  mercury  in  syphilis,  682 
Venous  heart  murmurs,  373 
Ventilation  in  acute  illness,  134 

of  nursery,  37 
Ventral  hernia,  756 

Vermiform  appendix,  anatomy  of,  252 
Vertebra,    cervical,    tuberculous    caries 

of,  278 
Vesical  calculus,  458 
Vesicular  breathing,  304,  305 
distant,  305 
exaggerated,  305 
Vincent's  angina,  285 
Virchow  on  cretinism,  729 
on  hemophilia,  412 
on  nsevus,  598 
on  necrobiosis,  164 
on  ossification  of  cranial  bones,  500 
Virus  in  acute  poliomyelitis,  537 
Viscera  in  tardy  hereditary  syphilis,  686 
Vocal  fremitus  in  lobar  pneumonia,  327 


Voegthn   and    McCallum    on   spasmo- 
philia, 494 
on  tetany,  494 
Vomiting,  219 

cyclic,  715.     See  also  Cyclic  vomiting. 

from  dilatation  of  stomach,  219 

from  pyloric  stenosis,  219 

in  icterus,  265 

in  infants,  management  of,  185 

in  lobar  pneumonia,  324 

in  pyloric  stenosis,  188 

obstinate,  gavage  in,  791 

of  blood,  182 

periodic,  715.     See  also  Cyclic  vomit- 
ing. 
appendicitis    and,    diflferentiation, 
254 

persistent,  in  acute  gastric  indiges- 
tion, treatment,  175 

recurrent,  715.     See  also  Cyclic  vomit- 
ing. 
von  Behring  on  bovine  tuberculosis,  693 
von  Eiselsberg  on  cretinism,  727 
von  Etlinger  on  hemophilia,  413 
von  Hecker  and  Buhl  on  hemorrhagic 

diseases  of  new-born,  157,  159 
von  Jaksch,  pseudoleukemic  anemia  of, 

406 
von   Mering  on  diabetes  mellitus,  735 
von  Pirquet  on  serum  disease,  708 
von  Pirquet's  tuberculin  test  in  tuber- 
culosis, 702 
von  Weisner  and  Leiner  on  acute  polio- 
myelitis, 537 
Vulvovaginitis,  gonorrheal,  466 

simple,  465 

Waddling     gait     in     pseudomuscular 
hypertrophy,  531 

Walbach  on  pyloric  stenosis,  188 

Walking  movements  for  bad  posture, 
778 
up   and   down   stairs   in    congenital 
ataxias,  839 

Warm  packs  in  acute  infective  menin- 
gitis, 552 

Washing,     stomach,     788.      See     also 
Lavage. 

Wassermann  test  for  syphilis,  704 
in  tardy  hereditary  syphilis,  689 

Wasting  palsy,  526 

Water,  drinking  of,  in  acute  illness,  134 
for  nursing  mother,  26 


INDEX 


913 


Water  to  drink  in  summer,  763 
Water-pressure   reduction   of   intussus- 
ception, 23ii 
Watt  on  whooping-cough,  614 
Weakened  breatliing,  306 
Weaning,  care  of  breasts  during,  30 
Weaver  and  TunnicHff  on  cancrum  oris, 

166 
Weaver  on  scarlet  fever,  643 
Webb  on  heUotherapy,  366 
Webber    on    cerebrospinal    meningitis, 

557 
Weighing  infants,  39,  124 
Weight  loss  in  pyloric  stenosis,  189 

of  new-born  infant,  38 
Welch's  treatment  of  hemorrhagic  dis- 
eases of  new-born,  160 
technic,  161 
Werdnig  and  Hoffmann  on  progressive 

amyotrophy,  526 
West  on  glandular  fever,  419 

on  tetany,  493 
Wet-brain    in    gastro-enteric    intoxica- 
tion, 195 
Wet-nurse,  33 

in  gastro-enteric  intoxication,  199 

in  marasmus,  88 

selection  of,  33 
Wheat  jelly,  formula  for,  70 
Whey-feeding,  64 

in  malnutrition,  94 
Whey,  formula  for,  71 
Whistler  on  rickets,  115 
Whooping-cough,  614 

bacteriology,  614 

climate  in,  773 

complications,  616 

diagnosis,  616 

fresh  air  in,  619 

history,  614 

incubation,  616 

infective  period,  615 

interrupted  medication  in,  618 

leukocytosis  in,  399 

pathology,  615 

prognosis,  617 

sedatives  in,  618 

susceptibility,  615 

symptoms,  616 

transmission,  615 

treatment,  617 


Wickman  on  acute  poliomyelitis,  539, 

540 
Widal  on  salt-free  diet  in  acute  neph- 
ritis, 446 
reaction  in  typhoid  fever,  707 
Wilcox  and  Miller  on  pyloric  stenosis, 
187 
on  tetany,  492 
Williams  on  scarlet  fever,  643 
Winckel    on    hemorrhagic    diseases    of 

new-born,  158 
Winckel's  disease,  158 
Window-board,  138 
Wolff-Eisner     tuberculin     reaction     in 

tuberculosis,  703 
WoUstein  and  Amoss  on  serum   treat- 
ment   of    cerebrospinal    meningitis, 
564 
WoUstein  and  Jacobi  on  fetal  tubercu- 
losis, 693 
WoUstein  on  influenza,  671 
on  lymphatic  leukemia,  407 
on  niumps,  611 
on  whooping-cough,  614 
Wood  on  blood  in  congenital  heart  dis- 
ease, 388 
on  transmission  of  epilepsy,  531 
Work  and  stress  as  factors  in  nutrition 

and  growth  of  new-born  infant,  20 
Wright     and     Douglas     on     opsonins, 

797 
Wright  on  blood  coagulation  in  hemo- 
phiha,  412 
on  scurvy,  112 

on  staphylococcus  vaccine  in  general 
septicemia,  799 
Wyeth  on  hypospadias,  464 

X-RAY.     See  Roentgen-ray. 

Yerberzine,  783 

in  malaria,  669 
Yersin  on  diphtheria,  626 
Young  on  trichiniasis,  251 

Zelenski-Cybulski  on  infantile  blood, 

396 
Zingher  and  Park  on  blood  transfusion, 
787 
on  Schick  reaction,  628 
Zwiefel  on  starch  digestion,  68 


58 


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DIAGNOSIS  AND    TREATMENT 


Cabot's  Works  on  Diagnosis 

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This  the  author  does  by  means  of  case-teachmg. 

The  symptom-groups  in  Vcjlume  I  (Third  Edition— January,  1915)  are:  Headache,  gen- 
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Volume  IT  (December,  1914)  :  Abdominal  and  other  tumors,  vertigo,  diarrhea,  dyspepsia, 
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infectious  diseases  are  taken  up  in  Part  II,  while  Part  111  deals  with  diseases  of 
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side,      'i'reatment,  naturally,  is  very  full.  PublisAcd  Ji^r.;,  1914 


PRACTICE    OF  MEDICINE 


Ward's  Bedside  Hematolog'y 

Bedside  Hematology.  By  Gordon  R.  Ward,  M.D.,  Fellow  ol  the 
Royal  Society  of  Medicine,  London,  England.  Octavo  of  394  pages, 
illustrated.    Published  April,  1914.  Clotli,  $3.50  net. 

INCLUDING  VACCINES  AND  SERUMS 

Dr.  Ward's  work  gives  you  the  exact  technic  for  obtaining  the  blood  for  ex- 
amination, the  making  of  smears,  the  blood-count,  finding  coagulation  time,  etc, 
Then  it  takes  up  each  disease,  giving  you  the  synonyms,  definition,  nature,  gen- 
eral pathology,  etiology,  bearings  of  age  and  sex,  the  onset,  symptomatology  (dis- 
cussing each  symptom  in  detail),  course  of  the  disease,  clinical  varieties,  compli- 
cations, diagnosis,  and  treatment  (drug,  diet,  rest,  vaccines  and  serums,  etc.). 


Faught's  Blood-Pressure 

Blood  =  Pressure  from  the  Clinical  Standpoint.  By  Francis  A. 
Faught,  M.  D.,  formerly  Instructor  :n  Medicine,  Medico-Chirurgical 
College  of  Philadelphia.  Octavo  of47  5  pages,  illustrated.  Cloth,  ^3.25  net. 

SECOND  EDITION— published  November.    1916 

Dr.  Faught' s  book  is  designed  for  practical  help  at  the  bedside.  Besides  the 
actual  technic  of  using  the  sphygmomanometer  in  diagnosing  disease,  Dr.  Faught 
has  included  a  brief  general  discussion  of  the  process  of  circulation.  The  practical 
application  of  sphygmomanometric  findings  within  recent  years  make  it  imperative 
for  every  medical  man  to  have  close  at  hand  an  up-to-date  work  on  this  subject. 


Smith's  What  to  Eat  and  Why 

What  to  Eat  and  Why.     By   G.    Carroll   Smith,  M.D.,  Boston. 

I2mO  of  377  pages.       Cloth,  $2.75   net.  Published  September,  1915 

SECOND  EDITION 

With  this  book  you  no  longer  need  send  your  patients  to  a  specialist  to  be 
dieted — you  will  be  able  to  prescribe  the  suitable  diet  yourself  just  as  you  do 
other  forms  of  therapy.  Dr.  Smith  gives  the  "why"  of  each  statement  he 
makes.  It  is  this  knowing  why  which  gives  you  confidence  in  the  book,  which 
makes  you  feel  that  Dr.  Smith  knows. 

Pennsylvania  Medical  Journal 

"All  through  this  book  Dr.  Smith  has  added  to  his  dietetic  hints  a  great  many  valuable  ones 
ol  a  general  nature,  which  will  appeal  to  the  general  practitioner." 


SAUNDERS'   BOOKS    ON 


Kolmer's  Specific  Therapy 

Infection,  Immunity,  and  Specific  Therapy.  By  John  A.  Kolmer, 
M.  D.,  Dr.  p.  H.,  Assistant  Professor  of  Experimental  Pathology,  Uni- 
versity of  Pennsylvania.  Octavo  of  900  pages,  with  143  original  illus- 
trations, 43  in  colors,  drawn  by  Erwin  F.  Faber.  New  (2d)  Edition  ready 
August.  1917. 

ORIGINAL  ILLUSTRATIONS 

Dr.  Kolmer' s  book  gives  you  a  full  account  of  infection  and  immunity,  and 
the  applicatioti  of  this  knowledge  in  the  specific  diagnosis,  prevention,  and  treat- 
ment of  disease.  The  section  devoted  to  imimmologic  technic  gives  you  every  de- 
tail, from  the  care  of  the  centrifuge  and  making  a  simple  pipet  to  the  actual  pro- 
duction of  serums  and  vaccines.  Under  specific  therapy  you  get  methods  of 
making  autogenous  vaccines  and  their  actual  use  in  diagnosis  and  treatment.  The 
directions  for  injecting  vaccines,  serums,  salvarsan,  etc. — with  the  exact  dosage — 
are  here  given  so  clearly  that  you  will  be  able  to  use  these  means  of  treatment  in 
your  daily  practice.  You  also  get  full  directions  for  making  the  clinical  diagnostic 
reactions — the  various  tuberculin  tests,  luetin,  mallein,  and  similar  reactions,  all  illus- 
trated with  colored  plates.     The  final  section  is  devoted  to  laboratory  experiments. 


Anders  (^  Boston's  Medical  Diagnosis 


(PubUshed  July,  1914) 


A  Text-Book  of  Medical  Diagnosis.  By  James  M.  Anders,  M.  D., 
Ph.D.,  LL.D., Professor  of  Medicine,  and  L.  Napoleon  Boston,  M.D., 
Professor  of  Physical  Diagnosis,  Medico-Chirurgical  College,  Graduate 
School  of  Medicine,  University  of  Pennsylvania.  Octavo  of  1 248  pages, 
with  466  illustrations.     Cloth,  $6.00  net ;  Half  Morocco,  ^7.50  net. 

SECOND  EDITION 

This  new  edition  is  designed  expressly  for  the  general  practitioner.  The 

methods  given  are  practical  and  especially  adapted  for  quick  reference.  The 

diagnostic  methods  are  presented  in  a  forceful,  definite  way  by  men  who  have 
had  wide  experience  at  the  bedside  and  in  the  clinical  laboratory. 

The  Medical  Record 

"  The  association  in  its  authorship  of  a  celebrated  clinician  and  a  well-known  laboratory 
worker  is  most  fortunate.     It  must  long  occupy  a  pre-eminent  position." 


THE  PRACTICE    OF  MEDICINE 


Anders' 
Practice   of  Medicine 


A  Text=Book  of  the  Practice  of  Medicine.  By  James  M.  Anders, 
M.  D.,  Ph.  D.,  LL.  D.,  Professor  of  Medicine,  University  of  Pennsylvania. 
Handsome  octavo,  1336  pages,  fully  illustrated.     Cloth,  $5.50  net;  Half 

Morocco,    ^7.00    net.  Published  September,  1915 

TWELFTH  EDITION 

The  success  of  this  work  is  no  doubt  due  to  the  extensive  consideration  given 
to  Diagnosis  and  Treatment,  under  Differential  Diagnosis  the  points  of  distinction 
of  simulating  diseases  being  presented  in  tabular  form.  In  this  new  edition 
Dr.  Anders  has  included  all  the  most  important  advances  in  medicine,  keepmg 
the  book  within  bounds  by  a  judicious  elimination  of  obsolete  matter.  A  great 
many  articles  have  also  been  rewritten. 

Wm.  E.  Quine,  M.  D., 

Professor  of  Medicine  and  Clinical  Medicine,  College  of  Physicians  and  Surgeons,  Chicago. 
"  I  consider  Anders'  Practice  one  of  the  best  single-volume  works  before  the  profession  at 
this  time,  and  one  of  the  best  text-books  for  medical  students." 


DaCosta's  Physical  Diag'nosis 

Physical  Diagnosis.  By  John  C.  DaCosta,  Jr.,  M.  D.,  Associate 
Professor  of  Medicine,  Jefferson  Medical  College,  Philadelphia.  Octavo 
of  589  pages,  with  243  original  illustrations.  Cloth,  $3.50  net 

THIRD   EDITION  -published  November.   1915 

Dr.  DaCosta's  work  is  a  thoroughly  new  and  original  one.  Every  methocn 
given  has  been  carefully  tested  and  proved  of  value  by  the  author  himself. 
Normal  physical  signs  are  explained  in  detail  in  order  to  aid  the  diagnostician  in 
determining  the  abnormal.  Both  direct  and  differential  diagnosis  are  emphasized. 
The  cardinal  methods. of  examination  are  supplemented  by  full  descriptions  of 
technic  and  the  clinical  utility  of  certain  instrumental  means  of  research. 

Dr.  Henry  L.   Eisner,   Professor  of  Aledicinc  at  Syracuse  University. 

"  I  have  reviewed  this  book,  and  am  thoroughly  convinced  that  it  is  one  of  the  best  ever 
written  on  this  subject.      In  every  way  I  find  it  a  superior  production." 


SAUNDERS'    BOOKS   ON 


Norris  O  Landis*  Physical 
Diagnosis 

Phy,sical  Diagnosis.  Part  I :  By  George  William  Norris,  A.  B., 
iVI.  D.,  Associate  in  Medicine  at  the  University  of  Pennsylvania;  Part  II : 
By  H.  R.  M.  Landis,  A.  B.,  M.  D.,  Director  of  Clinical  and  Sociological 
Department  of  the  Phipps  Institute,  Philadelphia.  Octavo  of  800 
pages,  with  325  illustrations,  mostly  original. 

STRONG   ON    INTERPRETATION 

This  work  presents  an  admirable  combination  of  the  theory  and  appHcations 
of  physical  diagnosis.  It  is  complete  down  to  the  last  detail.  The  first  part  takes 
up  the  methods  in  themselves.  Inspection,  palpation,  percussion,  and  ausculta- 
tion are  completely  covered  in  the  examination  both  of  the  lungs  and  of  the  heart. 
The  latter  is  amplified  by  a  chapter  on  the  electrocardiograph  by  Dr.  Edward  B. 
Krumbhaar.  The  second  part  takes  up  the  particular  diseases  of  the  bronchii,  of 
the  lungs,  of  the  pleura,  diaphragm,  pericardium,  heart  and  aorta,  and  shows  you 
exactly  how  to  determine  the  diagnosis  by  the  symptoms  and  findings.  You  get 
here  the  application  of  the  four  methods  to  your  daily  clinical  work. 

Priedenwald  and  Ruhrah  on  Diet 

Diet  in  Health  and  Disease.  By  Julius  Friedenwald,  M.  D., 
Professor  of  Diseases  of  the  Stomach,  and  John  Ruhrah,  M.  D.,  Pro- 
fessor of  Diseases  of  Children,  College  of  Physicians  and  Surgeons, 
Baltimore.      Octavo  of  857  pages.  Published  juiy,  1913. .  Cloth,  ^4.00  net. 

FOURTH   EDITION 

This  new  edition  has  been  carefully  revised,  making  it  stiil  more  useful  than  the  two 
•editions  previously  exhausted.  The  articles  on  milk  and  alcohol  have  been  rewritten,  additions 
made  to  those  on  tuberculosis,  the  salt-free  diet,  and  rectal  feeding,  and  several  tables  added, 
including  Winton's,  showing  the  composition  of  diabetic  foods. 

George  Dock,  M.  D. 

Professor  of  Theory  and  Practice  and  of  Clinical  Medicine,    Tulane   University. 
"  It  seems  to  me  that  you  have  prepared  the  most  valuable  work  of  the  kind  now  available, 
I  am  especially  glad  to  see  the  long  list  of  analyses  of  different  kinds  of  foods." 

Carter's  Diet  Lists 

Diet  Lists  of  the  Presbyterian  Hospital  of  New  York  City. 
Compiled,  with  notes,  by  Herbert  S.  Carter,  M.  D.  i2mo  of  129 
pages.  Published:::::',  1913  Cloth,  $1.00  net. 

Here  Dr.  Carter  has  cimiiiltd  nil   the  diet  li^ts  for  the  various  diseases  and  for  conva- 
lescence as  prescrilied  at  the  Presbyterian  Hospital.      Recipes  are  also  included. 


PRACTICE    OF  MEDICINE 


Kemp  on  Stomach* 
Intestines,  and  Pancreas 

Diseases  of  the  Stomach,  Intestines,  and  Pancreas.  By  Robert 
Coleman  Kemp,  M.  D.,  Professor  of  Gastro-intestinal  Diseases  at  the 
New  York  School  of  Clinical  Medicine.  Octavo  of  1096  pages,  with 
428  illustrations.     Cloth,  ;^7.oo  net ;   Half  Morocco,  $8.50  net, 

NEW  (3d)  EDITION— published  April.  1917 
The  new  edition  of  Dr.  Kemp's  successful  work  appears  after  a  most  search- 
ing revision.  Several  new  subjects  have  been  introduced,  notably  chapters  on 
Colon  Bacillus  Infectioti  and  on  Diseases  of  the  Pancreas,  the  latter  article  being 
really  an  exhaustive  monograph,  covering  over  one  hundred  pages.  The  section 
on  Duodenal  Ulcer  has  been  entirely  rewritten.  Visceral  Displacements  are  given 
special  consideration,  in  every  case  giving  definite  indications  for  surgical  inter- 
vention when  deemed  advisable.  There  are  also  important  chapters  on  the  hites- 
tinal   Complications  of  Typhoid  Fever  and  on  Diverticulitis. 

The  Therapeutic  Gazette 

"The  therapeutic  advice  which  is  given  is  excellent.  Methods  of  physical  and  clinical 
examination  are  adequately  and  correctly  described." 


Gant  on  Diarrheas 

Diarrheal,  Inflammatory,  Obstructive,  and  Parasitic  Diseases  of 
the  Ga>tro=intestinal  Tract.     By  Samuel    G.   Gant,   M.  D.,  LL.D., 

Professor  of  Diseases  of  Sigmoid  Flexure,  Colon,  Rectum,  and  Anus, 
New  York  Post-graduate  Medical  School  and  Hospital.  Octavo  of  604 
pages,  181  illustrations.     Cloth,  $6.00  net;  Half  Morocco,  ^7.50  net. 

ILLUSTRATED 

This  new  work  is  particularly  full  on  the  two  practical  phases  of  the  subject — 
diagnosis  and  treatment.  For  instance  :  While  the  essential  diagnostic  points  are 
given  under  each  disease,  a  fuller  description  of  diagnostic  methods  is  given  in  a 
special  chapter.  The  differential  diagnosis  of  diarrheas  of  local  and  those  of  sys- 
temic disturbances  is  strongly  brought  out.  There  is  a  special  chapter  on  7jer- 
vous  diarrheas  and  those  originating  from  gastrogenic  and  enterogenic  dyspepsias. 
You  get  methods  of  simultaneously  controlling  associated  constipation  and  diar- 
rhea. You  get  a  complete  for7nulary.  The  limitations  of  drugs  are  pointed  out, 
and  the  indications  and  technic  of  all  surgical  procedures  given.  June,  1915 

Gant  on  Constipation  and  Obstruction 

This  work  is  medical,  non-medical  (mechanical),  and  surgical,  the  latter  really 
being  a  complete  work  on  rectocolonic  surgery.  Second  Edition  October,  1916 

Octavo  of  575  pages,  with  250  illustrations.     By  Samuel  G.  Gant,  M.  D.     Cloth,  $6.00  net. 


SAUiYBERS'    BOOKS    OA' 


Sollmann's    Pharmacology 

A  Manual  of  Pharmacology :  Irs  Applications  to  Therapeutics 
AND  Toxicology.  By  Torald  Sollmann,  M.  D.,  Professor  of  Pharma- 
cology and  Materia  Medica  in  the  School  of  Medicine  of  Western  Re- 
serve University,  Cleveland.      Octavo  of  901  pages,  illustrated.     Cloth, 

$4.50  net.  Published  February,  1917 

JUST  OUT— BASED  ON  THE  1916  U.  S.  PHARMACOPOEIA 

J^  A  MfJ  A I  ^  This  is  the  text  or  reference  volume.  Two  sizes  of  type  are 
used.  The  broad  conceptions,  the  generalizations,  and  those 
detailed  discussions  of  great  and  practical  value  to  practitioner  and  student  are  set 
in  the  large  type.  The  mass  of  minute  details  is  set  in  the  smaller  type,  with 
frequent  side  headings  to  facilitate  quick  reference.  Throughout  the  work  the 
relation  of  phar))iacology  to  the  prat  ticc  of  medicine  \s  iorcWAy  emYih2iS\zt.d.  The 
really  important  drugs — those  drugs  that  you  actually  use  in  your  practice — are 
discussed  extensively,  while  those  used  less  frequently  are  dismissed  with  less  con- 
sideration. All  the  new  remedies  are  included,  with  detailed  instructions  for  their 
use  :  Vaccines,  serums,  salvarsan,  neosalvarsan,  pituitary  extract,  emetin — all 
those  new  remedies  of  the  Pharmacopoeia  being  so  extensively  discussed  and  em- 
ployed.     Every  worthwhile  development  in  the  field  of  pharmacology  is  included. 

LABORATORY    GUIDES.     ^^^   exercises   in   this   Laboratory    Gmde 

present  no  difficulty  in  technic,  and  re- 
quire little  help  from  the  instructor.  They  teach  you  how  to  teach  yourself.  Special 
stress  is  laid  on  facts  with  direct  practical  bearing.  The  experiments  on  animals 
are  arranged  in  groups  to  illustrate  various  types  or  phenomena,  to  bring  out  the 
similarities  and  differences  of  the  response  of  organs  to  pharmacologic  agents, 
rather  than  to  individual  drugs.  This  arrangement  articulates  better  with  the 
student's  experience  in  physiology  and  pathology. 

A    Laboratory  Guide  in   Pharmacology.    By  Torald  Sollmann,  M.  D.    Octavo  of  355  pages,  illustrated. 
Cloth,  $2.50  net. 

Arny*s  Pharmacy 

Principles  of  Pharmacy.  By  Henry  V.  Arny,  Ph.  D.,  Professor 
of  Chemistry,  New  York  College  of  Pharmacy.  Octavo  of  1056  pages, 
with  246  illustrations.      Cloth,  $5.50  net;  Half  Morocco,  $7.00  net. 

SECOND  EDITION— published  March.  1917 

Professor  Arny  divides  his  book  into  seven  parts:  The  first  part  deals  with  phar- 
maceutic processes,  a  striking  feature  being  the  clear  discussion  of  the  arithmetic 
of  pharmacy;  the  second,  with  galenic  preparations  of  the  Pharmacopoeia  and  those 
unofficial  preparations  of  proved  value;  the  third,  with  the  inorganic  chemicals, 
including  the  theories  of  chemistry;  the  fourth  discusses  the  organic  chemicals; 
the  fifth  is  devoted  to  chemical  testing,  presenting  a  systematic  grouping  of  all 
the  tests  of  the  Pharmacopoeia;  the  sixth  discusses  the  prescription  from  the  time 
it  is  written  until  it  is  dispensed;  the  seventh  is  devoted  to  laboratory  work,  with 
exercises  in  equation  writing  and  chemical  arithmetic. 

George  Reimann,  Ph.  G.,  Secretary  New   York  State  Board  of  Pharmacy 

"  I  would  say  that  the  book  is  certainly  a  great  help  to  the  student,  and  I  think  it  ought  to 
he  in  the  hands  of  every  person  who  is  contemplating  the  study  of  pharmacy." 


THERAPEUTICS  AND    EXERCISE  il 

Bastedo's   Materia    Medica 

Pharmacolog(y,    Therapeutics,    Prescription     Writing 

Materia  Medica,  Pharmacology,  Therapeutics,  and  Prescription 
Writing.  By  W.  A.  Bastedo,  Ph.  D.,  M.  D.,  Associate  in  Pharma- 
cology and  Therapeutics  at  Columbia  University,  New  York.     Octavo 

of  602  pages,  illustrated.  New  (2d;  Edition  ready  soon 

THREE  PRINTINGS  IN  SIX  MONTHS 

Dr.  Bastedo's  discussion  of  his  subject  is  very  complete.  As  an  illustration, 
take  the  pharmacologic  action  of  the  drug.  It  gives  you  the  antiseptic  action,  the 
local  action  on  the  skin,  mucous  membranes,  and  the  alimentary  tract  ;  where  the 
drug  is  obsorbed,  if  at  all — and  how  rapidly.  It  gives  you  the  systemic  action  on  the 
circulatory  organs,  respiratory  organs,  nervous  system,  and  sense  organs.  It  tells 
you  how  the  drug  is  changed  in  the  body.  It  gives  you  the  route  ot  elimination 
and  in  what  form.  It  gives  you  the  action  on  the  kidneys,  bladder,  urethra,  skin, 
bowels,  lungs,  and  mammary  glands  during  ehmination.  It  gives  you  the  after- 
effects. It  gives  you  the  unexpected — the  unusual — effects.  It  gives  you  the 
tolerance — habit  formation.  Could  any  discussion  be  more  complete,  more 
thorough  ? 

Boston  Medical  and  Surgical  Journal 

"  Its  aim  throughout  is  therapeutic  and  practical,  rather  than  theoretic  and  pharmacologic. 
The  text  is  illustrated  with  sixty  well-chosen  plates  and  cuts.  It  should  prove  a  useful  con- 
tribution to  the  text-book  literature  on  these  subjects." 


McKenzie  on  Exercise  in 
Education    and    Medicine 

Exercise  in  Education  and  Medicine.    By  R.  Tait  McKenzie,  B.  A. 

M.  D.,  Professor  of  Physical  Education  and  Director  of  the  Department, 

University  of  Pennsylvania.     Octavo  of  585   pages,  with  478  original 

illustrations.  Cloth,  S4.00  net. 

SECOND  EDITION— published  June.   1915 

D.  A.  Seu'g'ezmt,   M.   D.,  Director  of  Hemenway  Gymnasium.  Harvard  Uni'^ersity. 

"  It  cannot  fail  to  be  helpful  to  practitioners  in  medicine.  The  classification  of  athletic 
games  and  exercises  in  tabular  form  for  different  ages,  sexes,  and  occupations  is  the  work  of  an 
expert.     It  should  be  in  the  hands  of  every  physical  educator  and  medical  practitioner." 

Bonney's  Tuberculosis  second  Edition 

Tuberculosis.  By  Sherman  G.  Bonney,  M.  D.,  Professor  of  Medi- 
cine, Denver  and  Gross  College  of  Medicine.  Octavo  of  955  pages,  with 
243  illustrations.      Cloth,  $7.00  net ;   Half  Morocco,  $8.50  net. 

Maryland  Medical  Journal 

"  Dr.  Bonney's  book  is  one  of  the  best  and  most  exact  works  on  tuberculosis,  in  all  its 
aspects,  that  has  yet  been  published."  Published  May,  IQIO 


12  SAUNDERS'    BOOKS   ON 

Garrison's 
History  of  Medicine 

History  of  Medicine.  With  Medical  Chronology,  Bibliographic 
Data,  and  Test  Questions.  By  Fielding  H.  Garrison,  M.  D.,  Prin- 
cipal Assistant  Librarian,  Surgeon-General's  Office,  Washington,  D.  C. 

Cloth,  ^6.00  net  ;    Half  Morocco,  $7.50  net.  Published  December,  1913 

REPRINTED  IN  THREE  MONTHS— THE  BAEDEKER  OF  MEDICAL  HISTORY 

The  work  begins  with  ancient  and  primitive  medicine,  and  carries  you  in  a 
most  interesting  and  instructive  way  on  through  Egyptian  medicine,  Sumerian 
and  Oriental  medicine,  Greek  medicine,  the  Byzantine  period  ;  the  Mohammedan 
and  Jewish  periods,  the  Medieval  period,  the  period  of  the  Renaissance,  the  Re- 
vival of  learning  and  the  Reformation  ;  the  Seventeenth  Century  (the  age  of  indi- 
vidual scientific  endeavor),  the  Eighteenth  Century  (the  age  of  theories  and 
systems),  the  Nineteenth  Century  (the  beginning  of  organized  advancement  of 
science),  the  Twentieth  Century  (the  beginning  of  organized  preventive  medicine). 
You  get  "all  the  important  facts  in  medical  history;  a  biographic  dictionary;  an 
album  o{  77iedical portraits;  and  a  complete  medical  chronology. 

Stevens*    Therapeutics  Fifth  Edition.  September.  1909 

A  Text-Book  of  Modern  Materia  Medica  and  Therapeutics. 
By  A.  A.  Stevens,  A.  M.,  M.  D.,  Lecturer  on  Physical  Diagnosis  in 
the  University  of  Pennsylvania.     Octavo  of  675  pages.     Cloth,  ^3.50  net. 

Dr.  Stevens'  Therapeutics  is  one  of  the  most  successful  works  on  the 
subject  ever  published.  In  this  new  edition  the  work  has  undergone  a 
very  thorough  revision,  and  now  represents  the  very  latest  advances. 

rhe  Medical  Record,  New  York 

"  Among  the  numerous  treatises  on  this  most  important  branch  of  medical  practice, 
this  by  Dr.  Stevens  has  ranked  with  the  best." 

Butler's  Materia  Medica  sixth  Edition 

A  Text-Book  of  Materia  Medica,  Therapeutics,  and  Pharma- 
cology. By  George  F.  Butler,  Ph.  G.,  M.  D.,  Professor  and  Head 
of  the  Department  of  Therapeutics  and  Professor  of  Preventive  and 
Clinical  Medicine,  Chicago  College  of  Medicine  and  Surgery,  Medical 
Department  Valpariso  University.  Octavo  of  702  pages,  illustrated. 
Cloth,  $4.00  net;  Half  Morocco,  ^5.50  net.  Published  June,  iqos 

For  this  sixth  edition  Dr.  Butler  has  entirely  remodeled  his  work,  a  great 
part  having  been  rewritten.  All  obsolete  matter  has  been  eliminated,  and 
special  attention  has  been  given  to  the  toxicologic  and  therapeutic  effects 
of  the  newer  compounds. 

Medical  Record,  New  York 

"  Nothing  has  been  omitted  by  the  author  which,  in  his  judgment,  would  add  to  the 
completeness  of  the  text." 


THERAPEUTICS  AND   MATERIA    MEDICA  13 

Tousey's  Medical  Electricity 
Ront^en  Rays,  &nd  Radium 

Medical  Electricity,  Rontgen  Rays,  and  Radium.  By  Sinclair 
TousEY,  M.  D.,  Consulting  Surgeon  to  St.  Bartholomew's  Hospital, 
New  York.  Octavo  of  1219  pages,  with  801  illustrations,  ig  in  colors. 
Cloth,  $7.50  net;   Half  Morocco,  ^9.00  net.  Published  February,  1915 

SECOND  EDITION,  RESET 

The  revision  for  this  edition  was  extremely  heavy  ;  new  matter  has  increased  the  size 
of  the  book  by  some  100  pages.  About  50  new  illustrations  have  been  added.  The  new 
matter  added  includes :  Diathermy,  sinusoidal  currents,  radijography  with  intensifying 
screens,  rontgenotherapy,  the  Coolidge  and  similar  Rontgen  tubes  and  the  author's  method 
of  dosage,  and  radium  therapy  are  noted.  The  book  has  been  enriched  by  including  several 
of  Machado's  tabular  classifications  of  electric  methods,  effects,  and  uses. 

Throughout  the  entire  work  everything  concerning  electricity,  ^-rays,  and  radium  in 
medicine,  as  well  as  phototherapy,  is  explained  in  detail — nothing  is  omitted.  It  tells  you 
how  to  equip  your  office,  and,  more  than  that,  bow  to  use  your  apparatus,  explaining  away 
all  difficulties.  It  tells  you  just  how  to  apply  these  measures  in  the  treatment  of  disease. 
The  chapters  on  dental  radiography  are  particularly  valuable  to  those  interested  in  dental 
work. 


Deaderick  Cf  Thompson's  Endemic 
Diseases  of  South 

Endemic  Diseases  of  the  Southern  States.  By  William  H. 
Deaderick,  M.  D.,  Member  American  Society  of  Tropical  Medicine  ; 
and  LoYD  Thompson,  M.  D.,  Charter  Member  American  Association 
of  Immunologists.  Octavo  of  546  pages,  illustrated.  Cloth,  $5.00 
net ;   Half  Morocco,  $6.50  net.  Published  March,  1516 

THE  ONLY  WORK  OF  ITS  KIND 

This  work  records  the  experiences  of  two  active  practitioners  and  teachers 
right  in  the  field  and  thoroughly  familiar  with  these  diseases.  Those  diseases  of 
special  importance  are  given  unusual  consideration.  Pellag7-a,  for  instance,  is 
given  eight  chapters  for  its  full  consideration,  while  hookivorni  disease  covers  nine 
chapters  and  malaria  eight.  You  get  the  etiology,  pathology,  clinical  history, 
diagnosis,  prognosis,  prophylaxis,  and  treatment  of  each  disease,  presented  from 
every  angle,  always  bearing  in  mind  the  practical  aim  of  the  work — the  application 
of  the  knowledge  in  daily  practice. 


J4  SAUNDERS'    BOOKS   ON 


GET  /k  •  THE  NEW 

THE  BEST  /\  lit  6  n  C  Si  It  STANDARD 

Illustrated    Dictionary 


New  (8th)  Edition— 1500  New  Words 

The  American  Illustrated  Medical  Dictionary By  W.  A.  New- 
man Borland,  M.  D.,  Editor  of  "The  American  Pocket  Medical  Dic- 
tionary." Large  octavo  of  1 137  pages,  bound  in  full  flexible  leather. 
Price,  ;^4.50  net ;  with  thumb  index,  ;^5.oo  net.  Published  August,  191s 

KEY  TO  CAPITALIZATION  AND  PRONUNCIATION— ALL  THE  NEW  WORDS 

Howard  A.  }^eWy,^,Ti,,  Professor  of  Gynecologic  Surgery,  Johns  Hopkins  University. 

"  Dr.  Dorland's  dictionary, is  admirable.  It  is  so  well  gotten  up  and  of  such  convenient 
size.     No  errors  have  been  found  in  my  use  of  it." 


Thornton's  Dose-Book.  Fourth  Edition 

Dose-Book  and  Manual  of  Prescription-Writing.  ByE.  Q.  Thornton,  M.D., 
Assistant  Professor  of  Materia  Medica,  Jefferson  Medical  College,  Philadelphia.  Post- 
octavo,  4IO  pages,  illustrated.     Flexible  leather,  ^2.00  net.  Published  September,  1909 

"  I  will  be  able  to  make  considerabla  use  of  that  part  of  its  contents  relating  to  the  correct 
terminology  as  used  in  prescription-writing,  and  it  will  afford  me  much  pleasure  to  recom- 
mend the  book  to  my  classes,  who  often  fail  to  find  this  information  in  their  other  text- 
books."— C.  H.  Miller,  M.T).,  Professor  of  Pharmacology ,  Norfhwesiem  University  Medi- 
cal School. 

Lusk    on    Nutrition  New  (3d)  Edition 

Elements  of  the  Science  of  Nutrition.     By  Graham  Lusk,  Ph.  D.,  Professor 

of   Physiology  in    Cornell   University  Medical  School.     Octavo  of  641  pages.      Cloth, 

$4.50  net.  PubUshed  July,  1917 

"  I  shall  recommend  it  highly.     It  is  a  comfort  to  have  such  a  discussion  of  the  subject." 

— Lfwellys  F.  Barker,  M.  T).,  Johns  Hopkins  University. 

Camac's  '* Epoch-making  Contributions*' 

Epoch-making  Contributions  in  Medicine  and  Surgery.  Collected  and 
arranged  by  C.  N.  B.  Camac,  M.  D.,  of  New  York  City.  Octavo  of  450  pages,  illus- 
trated.    Artistically  bound,  ^4.00  net.  Published  January,  1909 

"  Dr.  Camac  has  provided  us  with  a  most  interesting  aggregation  of  classical  essays^ 
We  hope  that  members  of  the  profession  will  show  their  appreciation  of  his  endeavors."— 
Iherapeutic  Gazette. 


PRACTICE,    MATERIA   MEDICA,   Etc.  \%^ 

The  American  Pocket  Medical  Dictionary  New  (pth)  Edition 

The  American  Pocket  Medical  Dictionary.  Edited  by  W.  A.  Newman  Dor- 
land,  M.D.,  Editor  "American  Illustrated  Medical  Dictionary."  693  pages.  Flexible 
leather,  with  gold  edges,  #1.25  net;   with  thumb  index,  $1.50  net,  April,  1915 

Strouse  O  Perry's  Food  Manual  for  Doctor  and  Patient 

A  Food  Manual  for  Doctor  and  Patient.  By  Solomon  Strouse,  A.  B.,  M.  D., 
Professor  of  Medicine,  Post-Graduate  Medical  School,  Chicago;  and  Maude  A. 
Perry,  B.  S.,  Dietitian  Michael  Reese  Hospital.  i2mo  of  270  pages.  Cloth,  $1.50 
net.  Published  August,  1917 

Here  the  science  of  nutrition  is  detailed  for  the  layman,  and  the  physician  finds 
his  abstract  theories  translated  into  the  terminology  of  the  kitchen.  Diets  are  given 
for  diabetes  (starvation  treatment),  gout,  nephritis,  high  blood-pressure,  kidney  stone, 
diseases  of  the  stomach,  intestines,  liver,  gall-stones,  tuberculosis,  fevers,  skin  affec- 
tions, obesity,  anemia,  etc.  There  are  in  all  232  diets  and  menus,  and  124  special 
recipes. 

Cohen   and    Eshner's   Diagnosis.  Second  Revised  Edition.  1900 

Essentials  of  Diagnosis.  By  S.  Solis-Cohen,  M.  D.,  Senior  Assistant  Professor 
in  Clinical  Medicine,  Jefferson  Medical  College,  Phila.  ;  and  A.  A.  Eshner,  M.  D., 
Professor  of  Clinical  Medicine,  Philadelphia  Polyclinic.  Post-octavo,  382  pages  ;  55 
illustrations.      Cloth,  ;^I. 25  net.     In  Saunders'  Qitestion-Compeud  Series. 

Morris*  Materia  Medica  and  Therapeutics.  Seventh  Edition 

Essentials  of  Materia  Medica,  Therapeutics,  and  Prescription-Writing. 
By  Henry  Morris,  M.  D.,  late  Demonstrator  of  Therapeutics,  Jefferson  Medical 
College,  Phila.  Revised  by  W.  A.  Bastedo,  M.  D.,  Instructor  in  Materia  Medica  and 
Pharmacology  at  Columbia  University,  1 2mo,  300  pages.  Cloth,  ^1.25  iiel.  In  Sounder'' 
Question- Cotn-pend  Series.  Published  November,  IQ05 

Kelly's  Cyclopedia  of  American  Medical  Biography 

Cyclopkdia  of  American  Medicai,  Biography.  P>y  Howard  A.  Kki.i.y,  M.  D., 
Johns  Hopkins  Univer-^ity.  Two  octavos  of  525  pages  each,  with  portraits.  Per  set: 
Clotli,  ^10.00  net  ;    Half  Morocco,  ^13.00  net.  Published  April,  1912 

Oertel  on  Bright' s  Disease  illustrated 

The  Anatomic  Histological  Processes  of  Bright's  Disease.  By  Horst 
Oertel,  M.  D  ,  Director  of  the  Russell  Sage  Institute  of  Pathology,  New  York.  Octavo 
of  227  pages,  with  44  text-cuts  and  6  colored  plates.     Cloth,  $5.00  net.  December,  1910 

Arnold's  Medical  Diet  Charts 

Medical  Diet  Charts.  Prepared  by  H.  D.  Arnold,  M.  D.,  Dean  of  Harvard 
Graduate  Medical  School.  Boston.  Single  charts,  5  cents;  50  charts,  ^2.00  net;  500 
charts,  $18.00  net ;    looo  charts,  $30.00  net. 

Eggleston's  Prescription  Writing 

Essentials  of  Prescription  Writing.  By  Gary  Eggleston,  M.  D.,  Instructor 
in  Pharmacology,  Cornell  University  Medical  School.  i6mo  of  125  pages.  Cloth,  $1.00 
jjgt  Published  September,  1913 


»6  SAUNDEJ^S'   BOOKS  ON  PRACTICE,   Etc. 


Slade's  Physical  Examination  and  Diagnostic  Anatomy 

Physical  Examination  and  Diagnostic  '  Anatomy.  By  Charles  B.  Slade, 
M.  D.,  formerly  of  University  and  Bellevue  Medical  School.  i2mo  of  150  pages' 
illustrated.  Second  Edition— published  September,  1916.  Cloth,  $1.25  net' 

Abbott's  Medical  Electricity 

Medical  Electricity.  By  George  Knapp  Abbott,  M.  D.,  Dean  and  Pro- 
fessor of  Physiologic  Therapy  and  Practice.  College  of  Medical  Evangelists,  Loma  Linda, 
California.      l2mo  of  132  pages,  illustrated.     Cloth,  ^1.25  net.  April,  1915 

Stevens'  Practice  of  Medicine  New  (loth)  Edition 

A  Manual  of  the  Practice  of  Medicine.     By  A.  A.  Stevens,  A.  M.,  M.  D., 

Professor   of    Pathology,    Woman's   Medical    College,    Phila.  Specially   intended   foi 

students  preparing  for  graduation  and   hospital  examinations.  Post-octavo,  629  pages, 

illustrated.      Cloth,  $2.50  net.  Published  July,  i9lS 

Saunders*  Pocket  Formulary  New  (9th)  Edition 

Saunders'  Pocket  Medical  Formulary.  By  William  M.  Powell,  M.  D. 
Containing,  1831  formulas  from  the  best-knovi^n  authorities.  With  an  Appendix  con- 
taining Posologic  Table,  Formulas  and  Doses  for  Hypodermic  Medication,  Poisons  and 
their  Antidotes,  Diameters  of  the  Female  Pelvis  and  Fetal  Head,  Obstetrical  Table, 
Diet-list,  Materials  and  Drugs  used  in  Antiseptic  Surgery,  Treatment  of  Asphyxia  from 
Drowning,  Surgical  Remembrancer,  Tables  of  Incompatibles,  Eruptive  Fevers,  etc., 
etc.     In  flexible  leather,  with  side  index,  wallet,  and  flap,  ^1.75  net.  January,  1909 

De&derick  on  Malaria 

Practical  Study  of  Malaria.  By  William  H.  Deaderick,  M.  D.,  Member 
American  Society  of  Tropical  Medicine ;  Fellow  London  Society  of  Tropical  Medicine 
and  Hygiene.  Octavo  of  402  pages,  illustrated.  Cloth,  ^^4.50  net;  Half  Morocco,. 
^6.00  net.  Published  Novembei,  1909 

NileS    on    Pellagra  second  Edition— January,  1916 

Pellagra.       By    George    M.   Niles,    M.  D.,   Gastro-enterologist  to  the  Georgia 
Baptist  Hospital,  Atlanta.      Octavo  of  225  pages,  illustrated.      Cloth,  ^3.00  net. 

Hinsdale's  Hydrotherapy 

Hydrotherapy.  By  Guy  Hinsdale,  M.  D.,  Fellow  Royal  Society  of  Medicine 
of  Great  Britain.      Octavo  of  466  pages,  illustrated.     Cloth,  ^3.50  net.  August,  1910 

Todd's    Clinical    Diagnosis  Third  Edition-October.  1914 

Clinical  Diagnosis:  A  Manual  of  Laboratory  Methods.  By  J.-vmes  Camp- 
bell Todd,  M.  D.,  Professor  of  Pathology,  University  of  California,  izmo  of  585 
pages,  illustrated.     Cloth,  $2.50  net. 

This  book  gives  you  the  exact  lechnic,  the  precise  procedure  to  follow  down  to  the  smallest  detail. 
An  extremely  important  section  is  that  on  the  use  of  the  microscope,  giving  you  the  various  parts,  how 
to  prepare  the  material,  make  slides,  and  interpret  the  findings.  The  third  edition  has  been  brought 
right  down  to  the  minute.  The  contents  include  70  pages  on  the  therapeutic  use  of  vaccines  and  sero- 
diagnosis,  taking  up  the  preparation  of  autogenous  vaccines,  Abderhalden's  serum  test  for  ectopic  preg- 
nancy, the  urease  methods  for  urea,  the  Rimini-Burnam  test  for  formaldehyd,  Huntoon's  method  for 
spores,  Ponder's  stain  for  diphtheria  bacilli,  and  the  luetin  reaction. 

"A  distinct  improvement  on  many  of  its  predecessors  of  similar  scope.  -  It  deals  with  all  the  examina- 
tions  which  the  clinician  may  have  to  undertake  in  the  course  of  his  viork."— British  Medical  Journal,. 


K45 

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